The nurse is caring for a patient with peripheral arterial ...

[viki]

The nurse is caring for a patient with peripheral arterial disease who complains of 3/10 pain in the lower extremities. The nurse observes a 0.5 cm  1 cm ulcer on the left lower leg, and the lower legs are shiny and hairless bilaterally.
 
  The nurse identifies which priority problem state-ment/nursing diagnosis?
  a. Injury related to loss of peripheral circula-tion.
  b. Acute pain related to ischemia to lower extremities.
  c. Altered skin integrity related to ulcers on lower extremities.
  d. Insufficient knowledge related to new di-agnosis of hypertension.

Question 2

The nurse is caring for a patient with C. difficile infection. Which action is most important for the nurse to take?
 
  a. Only use alcohol-based hand cleanser for hand hygiene.
  b. Always wear an impervious mask.
  c. Don proper eye protection before provid-ing care.
  d. Notify housekeeping to use appropriate cleaning agents.

[mtmmmmmk]

Answer to Question 1

C
Altered skin integrity is the priority problem statement/diagnosis in this situation. Acute pain is a nursing diagnosis, but the pain is 3/10 so it is not the priority since there is an open wound. Injury and insufficient knowledge could be problems, but there is not enough information to support these diagnoses.

Answer to Question 2

D
Notification of housekeeping to use alcohol-free cleaners is necessary in order to eradicate the pathogen. Soap and water must be used after contact with this organism because alcohol-based hand sanitizers do not adequately kill the microorganism. A mask and eye protection are not ne-cessary.

[viki]

Thank you

[mtmmmmmk]

No problemo