A client with a history of a right radical mastectomy arrives on the postoperative unit following surgical repair of a fractured left radius and application of a short arm cast. Which action should the practical nurse implement while obtaining the client's blood pressure (BP)?

Choice A reason: Placing the food and utensils in the client's left visual field and leaving him alone does not address the underlying issue of the visual field deficit. While it may temporarily solve the problem of the client eating only the food on the left side, it does not encourage the client to adapt to or compensate for the right homonymous hemianopsia. The goal of rehabilitation is to help the client develop strategies to manage their condition independently, and this approach does not foster such skills.
Choice B reason: Feeding the client foods that are on the right side of his visual field is not the most effective approach, as it does not promote the client's independence or help them adapt to their visual field deficit. While it ensures the client consumes the food on the right side, it does not teach the client to compensate for their hemianopsia, which is an essential aspect of their rehabilitation.
Choice C reason: Reminding the client to look all over the tray to view and eat all the foods provided is the best approach. This action helps the client become more aware of their visual field deficit and encourages them to develop the habit of scanning their environment. Teaching the client to consistently look around their entire visual field promotes independence and helps them adapt to daily activities despite their condition. This strategy supports the goal of rehabilitation, which is to enhance the client's ability to manage their visual impairment independently.
Choice D reason: Prompting the client to rotate his plate to see foods on the right side of the tray is a practical solution, but it does not address the broader need for the client to learn to scan their environment. While rotating the plate may temporarily help the client access the food on the right side, it does not encourage the development of compensatory strategies for the visual field deficit. Encouraging the client to look all over the tray is a more effective approach for long-term adaptation and independence.

Choice A reason: Bathing the wound daily with soap and water is a common practice to maintain cleanliness and prevent infection in a wound. However, this is not the immediate priority in this scenario. The presence of a dusky color on the left foot indicates potential vascular compromise, which needs to be assessed first to ensure adequate blood flow to the affected area. Cleaning the wound can be done subsequently, but checking circulation is critical to address any immediate risks.
Choice B reason: Recording the color and temperature of the leg is an important assessment step to monitor the client's condition. These observations can provide valuable information about the client's peripheral circulation and skin condition. However, while this should be done as part of the overall assessment, it is not the most immediate action. Checking the pulses will give more direct information about the blood supply to the affected area, which is crucial for identifying any urgent circulatory issues.
Choice C reason: Performing dorsiflexion and extension exercises can help maintain joint mobility and muscle strength in clients with diabetes. However, it is not the first intervention that should be implemented in this scenario. Before recommending exercises, it is essential to assess the vascular status of the client's foot. Exercises may not be appropriate if there is significant circulatory compromise, and could potentially cause further harm.
Choice D reason: Checking the client's dorsalis pedis and posterior tibialis pulse points is the most critical first intervention. The dusky color of the foot suggests a possible issue with blood flow. By assessing the pulses in the foot, the practical nurse can determine if there is adequate perfusion to the area. If the pulses are weak or absent, it may indicate peripheral artery disease or another vascular issue that requires immediate medical attention. Prompt identification and intervention are crucial to prevent further complications, such as tissue necrosis or limb-threatening ischemia.