44. A nurse is preparing to provide foot care for a client who is ambulatory. Identify the sequence of steps the nurse should follow when performing foot care. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Gently dry the client's feet and areas between the toes with a towel.
Assist the client into a sitting position in a chair.
Soak the client's feet in warm water.
Apply lotion to the client's feet.
Rub callused areas of the client's feet using a washcloth.
The Correct Answer is B,C,E,A,D
- Assist the client into a sitting position in a chair. Ensures comfort and stability before starting foot care.
- Soak the client's feet in warm water. Softens the skin and makes cleaning easier.
- Rub callused areas of the client's feet using a washcloth. Helps remove dead skin and promotes circulation.
- Gently dry the client's feet and areas between the toes with a towel. Prevents moisture buildup, which can lead to fungal infections.
- Apply lotion to the client's feet. Moisturizes the skin but should not be applied between the toes to prevent excessive moisture retention and fungal growth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Remove clocks from the client's room." –
Removing clocks can increase confusion and disorientation. Instead, having a visible clock and calendar can help the client stay oriented.
B. "Check on the client frequently while he is in the restroom." –
While frequent monitoring is important, excessive surveillance may increase agitation and distress. A better alternative is to ensure the restroom is safe and accessible.
C. "Encourage physical activity throughout the day to expend energy." –
Engaging the client in physical activity helps reduce restlessness, promotes better sleep, and decreases the likelihood of agitation, which can reduce the need for restraints.
D. "Use full-length side rails on the client's bed." –
Full-length side rails can be considered a form of restraint as they may limit movement and increase the risk of falls or injury if the client tries to climb over them.
Correct Answer is ["A","B","C","D","E","F","G","H"]
Explanation
The key pieces of information that indicate the client is at risk for falls include:
- Admitted following a fall down approximately five steps – Indicates a recent fall history.
- Client's partner reports client possibly hit their head and was a little disoriented for a minute or two – Suggests potential confusion or altered mental status.
- Client has a history of falls and orthostatic hypotension per client's partner – A significant risk factor for future falls.
- Client uses a walker – Indicates mobility impairment.
- Client ordered new glasses following an eye exam last week but has not received them yet – Vision impairment increases fall risk.
- Blood pressure: Lying: 130/90 mm Hg, Sitting: 128/88 mm Hg, Standing: 98/60 mm Hg – Orthostatic hypotension (drop in BP upon standing) can cause dizziness and falls.
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