A client with diabetes is admitted with a 1 cm size ulcer on the left great toe. The practical nurse (PN) observes that the left foot has a dusky color. While planning the client's care, which intervention should the PN implement first?

Bathe the wound daily with soap and water.

Record the color and temperature of the leg.

Perform dorsiflexion and extension exercises.

Check the client's dorsalis pedis and posterior tibialis pulse points.

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is C

Explanation

Choice A reason: Returning for a urine culture and imaging is an important part of follow-up care for a client with pyelonephritis. These tests can help ensure that the infection has been completely resolved and that there are no underlying structural abnormalities contributing to the condition. However, while follow-up appointments are crucial, the immediate priority for discharge instructions is to emphasize the importance of adhering to the prescribed medication regimen to ensure the effectiveness of the treatment.
Choice B reason: Using nonsteroidal anti-inflammatory drugs (NSAIDs) for pain can help manage discomfort associated with pyelonephritis. However, pain management is secondary to ensuring that the infection is effectively treated. While it is important to address the client's pain, reinforcing the need to follow the prescribed medication regimen takes precedence to ensure that the infection is adequately managed and prevented from worsening or recurring.
Choice C reason: Adhering strictly to the medication regimen is the most important instruction for the client. Ensuring that the client takes the full course of prescribed antibiotics is critical to effectively treating the pyelonephritis and preventing the development of antibiotic resistance or recurrent infections. Reinforcing the importance of completing the antibiotic course as directed helps ensure that the infection is fully eradicated and reduces the risk of complications.
Choice D reason: Ensuring effective perineal hygiene is important for preventing urinary tract infections (UTIs) and maintaining overall urinary health. While it is a relevant aspect of care, it is not the most critical instruction for the client at the point of discharge. The primary focus should be on the adherence to the medication regimen to treat the current infection and prevent further complications. Perineal hygiene practices can be reinforced as part of overall health education but are not the immediate priority compared to medication adherence.

A. Respiratory rate. B. Urinary output. C. Temperature. D. Blood pressure.

Correct Answer is D

Explanation

Choice A reason: While respiratory rate is an important vital sign to monitor, changes in respiratory rate are not the most critical indicator of an imminent complication related to an abdominal aneurysm. Respiratory rate can be influenced by various factors such as pain, anxiety, or underlying respiratory conditions. However, it does not directly correlate with the risk of aneurysm rupture, which is the primary concern in clients with an abdominal aneurysm.
Choice B reason: Urinary output is an important indicator of renal function and overall fluid balance. However, changes in urinary output are not the most immediate concern in the context of an abdominal aneurysm. While it is essential to monitor urine output to ensure adequate kidney function, it is not the primary parameter that would signal an imminent complication or rupture of the aneurysm.
Choice C reason: Temperature can provide valuable information about the presence of an infection or systemic inflammation. However, changes in temperature are not directly related to the risk of aneurysm rupture. Although an elevated temperature may warrant further investigation, it is not the most critical finding to report in the context of an abdominal aneurysm.
Choice D reason: Blood pressure is the most important assessment finding to monitor and report in a client with an abdominal aneurysm. Elevated blood pressure can increase the risk of aneurysm rupture due to the added stress on the arterial wall. Conversely, a sudden drop in blood pressure can indicate a potential rupture or internal bleeding, which is a medical emergency. Monitoring and reporting changes in blood pressure are crucial in providing timely interventions to prevent or address complications related to an abdominal aneurysm.

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A client with diabetes is admitted with a 1 cm size ulcer on the left great toe. The practical nurse (PN) observes that the left foot has a dusky color. While planning the client's care, which intervention should the PN implement first?

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is caring for a client with pyelonephritis who is admitted for parenteral anti-infective therapy. Prior to discharge home with an oral medication regimen, which instruction is most important for the practical nurse (PN) to reinforce with the client?

Correct Answer is C

Explanation

When providing preoperative care for a client with an abdominal aneurysm, changes in which assessment finding are most important for the practical nurse (PN) to report to the registered nurse (RN)?

Correct Answer is D

Explanation

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