Tissue integrity passpoint

B

Which indicates hypovolemic shock in a client who has had a 15% blood loss? a) pulse rate less than 60 bpm b)systolic blood pressure less than 90 mm Hg c)pupils unequally dilated d)respiratory rate of 4 breaths/minute

B

A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used? a)Specialty mattress b) Ring or donut c) Water bed d) Gel flotation pad

A

For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse assesses the wound. Which finding indicates wound healing? a) The granulation tissue is at the wound edges. b)The wound drainage is serous. c)The skin around the wound is edematous. d)The tissue surrounding the wound is red and hot.

D

The nurse is caring for an elderly client with a fractured hip who is on bed rest. Which nursing interventions would be included on the plan of care? a)Provide only passive range of motion (ROM), and decrease stimulation. b)Have the client lie as still as possible, and give adequate pain medication. c)Encourage coughing and deep breathing, and limit fluid intake. d) Turn the client every 2 hours, and encourage coughing and deep breathing.

C

Which nursing diagnosis is a priority for a client with a traumatically amputated lower extremity? a) Disturbed body image related to changes in the structure of a body part b) Anticipatory grieving related to the loss of a limb c)Risk for injury related to amputation d) Impaired skin integrity related to effects of the injury