Practice questions!

[dudette10, MSN, RN]

I mentioned in a previous thread that I'm in an MSN-ed program, and I had to do a group project in which my partner and I created 10 test items, tested them with 20 people (half of which were nursing students or new grads), and statistically analyzed them.

I'm going to give you the questions from that project, one at a time. After the some discussion, I'll give the answer, rationale, and test statistics.

Ready? Ok!

A nurse is reviewing vital signs, shown below, for a patient currently being treated for a Stage III sacral decubitus ulcer. What is the priority nursing diagnosis for this patient?

[TABLE]

[TR]

[TD]Time[/TD]

[TD]0730[/TD]

[TD]1140[/TD]

[TD]1545[/TD]

[/TR]

[TR]

[TD]Temperature[/TD]

[TD]98.6 degrees Fahrenheit[/TD]

[TD]99.0 degrees Fahrenheit[/TD]

[TD]99.0 degrees Fahrenheit[/TD]

[/TR]

[TR]

[TD]Respiration Rate[/TD]

[TD]18 breaths per minute[/TD]

[TD]20 breaths per minute[/TD]

[TD]24 breaths per minute[/TD]

[/TR]

[TR]

[TD]Heart Rate[/TD]

[TD]63 beats per minute[/TD]

[TD]62 beats per minute[/TD]

[TD]55 beats per minute[/TD]

[/TR]

[TR]

[TD]Blood Pressure[/TD]

[TD]105/70 mmHg[/TD]

[TD]103/65 mmHg[/TD]

[TD]96/62 mmHg[/TD]

[/TR]

[TR]

[TD]SpO2[/TD]

[TD]97% on room air[/TD]

[TD]98% on room air[/TD]

[TD]97% on room air[/TD]

[/TR]

[/TABLE]

1. Ineffective tissue perfusion
   
2. Risk for infection
   
3. Impaired skin integrity
   
4. Impaired oral nutrition, less than body requirements
   

[loving2024, BSN, RN]

Due to the decrease in BP and HR then ineffective tissue perfusion would be my priority. The patient already has circulation issue due to her stage 3 ulcer.

I think you should add ineffective breathing pattern as one of the options