The client has a documented stage II pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate to use with this client?

Risk for Injury

Altered Tissue Perfusion

Impaired Tissue Integrity

Impaired Skin Integrity

Answer and Explanation

The Correct Answer is D

A stage II pressure ulcer is a wound that involves partial-thickness loss of skin. The most appropriate NANDA nursing diagnosis problem statement for a client with this condition would be Impaired Skin Integrity. This diagnosis reﬂects the fact that the client's skin has been damaged and is no longer intact. Risk for Injury, Altered Tissue Perfusion, and Impaired Tissue Integrity are also NANDA nursing diagnoses, but they are not as specific or relevant to the client's condition as Impaired Skin Integrity.

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Correct Answer is D

Explanation

When collecting equipment to administer a unit of packed red blood cells, the nurse should use 250 mL of normal saline to initiate the IV for this transfusion ³. Normal saline is the only compatible solution to use with blood or blood components ³. The other options (100 mL of 5% dextrose and 1/2 normal saline, 1,000 mL of lactated Ringer's solution, and 500 mL of 5% dextrose and water) are not appropriate IV ﬂuids to use when administering a unit of packed red blood cells.

A. Not talkative B. Pale and diaphoretic C. "Leave me alone" D. Restlessness E. Encourage or provide oral hygiene after mealtime.

Correct Answer is C

Explanation

Subjective data refers to information that is reported by the client and cannot be directly observed or measured by the healthcare provider. In this case, the statement "leave me alone" is an example of subjective data that the nurse should document. This information provides insight into the client's feelings and emotions and can help guide the nurse's care and interventions.

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The client has a documented stage II pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate to use with this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV ﬂuid should be used to initiate the IV for this transfusion?

Correct Answer is D

Explanation

During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed and says "leave me alone." Which subjective data should the nurse document?

Correct Answer is C

Explanation

The nurse is identifying outcomes for a client with the nursing diagnosis of Stress Urinary Incontinence. Which outcome would be related to sphincter incompetence?

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