The nurse is caring for a client who is diagnosed with an arterial insufficiency ulcer. The nurse should plan interventions to address which priority issue?
Chronic pain
Impaired skin integrity
Risk for injury
Ineffective tissue perfusion
The Correct Answer is D
A. Chronic pain - Chronic pain is a concern for the client, but addressing the underlying issue of ineffective tissue perfusion will help alleviate pain by promoting healing and reducing tissue damage.
B. Impaired skin integrity - Impaired skin integrity is a result of ineffective tissue perfusion. By addressing perfusion issues, skin integrity can be improved as tissues receive adequate oxygen and nutrients for healing.
C. Risk for injury - While clients with arterial insufficiency ulcers are at risk for injury, the immediate concern is addressing the ineffective tissue perfusion to prevent complications related to poor circulation, such as tissue necrosis and infection.
D. Ineffective tissue perfusion- Arterial insufficiency ulcers are caused by inadequate blood flow to the tissues. The priority issue for a client with an arterial insufficiency ulcer is ineffective tissue perfusion. Due to decreased blood flow, tissues do not receive enough oxygen and nutrients, leading to delayed wound healing, tissue damage, and potential complications. Interventions should focus on improving circulation, promoting vasodilation, and enhancing perfusion to facilitate wound healing and prevent further tissue damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. There is no need for the client to lie flat for an extended period after a DEXA scan. The procedure is non-invasive and does not require immobilization.
B. Emptying the bladder before the test is essential to ensure a clear and accurate scan of the pelvis and lower spine. A full bladder might obstruct the view and affect the accuracy of the results.
C. DEXA scans do not typically require the use of IV dye. It is a simple X-ray procedure that measures bone density, and no contrast material is usually needed.
D. Fasting is not necessary for a DEXA scan. The procedure does not involve ingesting or injecting any substances that require fasting.
Correct Answer is ["84.1"]
Explanation
Weightinkg=185÷2.2≈84.1
Calculate the dose of enoxaparin:
The prescribed dose is 1 mg/kg.
Doseinmg=Weightinkg×Doseperkg
Doseinmg=84.1×1≈84.1
The nurse should administer 84.1 mg of enoxaparin.
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