A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. The client reports his feet feel uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement?

Use a bed cradle to hold the covers off feet.

Provide a warming pad (Aqua-pad or K-pad) to feet.

Place warm blankets next to the client’s feet.

Medicate the client with a prescribed sedative.

Answer and Explanation

The Correct Answer is B

Choice A reason: Using a bed cradle to hold the covers off feet is not a good option for a client with DM and right hemiplegia, because it can increase the risk of injury and infection to the feet. The client may have reduced sensation and circulation in the feet due to diabetic neuropathy and peripheral vascular disease, which can make the feet more prone to ulcers, gangrene, and amputation. The client should keep the feet covered and protected from pressure and trauma.

Choice B reason: Providing a warming pad (Aqua-pad or K-pad) to feet is the best option for a client with DM and right hemiplegia, because it can help improve the blood flow and comfort to the feet. The warming pad is a device that circulates warm water or air through a pad that is placed on the skin. The nurse should monitor the temperature and duration of the warming pad, and check the skin for signs of burns or blisters.

Choice C reason: Placing warm blankets next to the client’s feet is not a reliable option for a client with DM and right hemiplegia, because it may not provide enough warmth and may slip off during the night. The client may not be able to adjust the blankets due to the hemiplegia, which can affect the movement and strength of the right side of the body. The client may also have difficulty feeling the blankets due to the neuropathy.

Choice D reason: Medicating the client with a prescribed sedative is not a suitable option for a client with DM and right hemiplegia, because it does not address the underlying cause of the cool feet, and may have adverse effects on the client’s condition. The sedative may interact with the client’s other medications, such as insulin or oral hypoglycemics, and cause hypoglycemia, which can worsen the stroke recovery. The sedative may also cause respiratory depression, which can affect the oxygen delivery to the brain and the feet.

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Correct Answer is A

Explanation

Choice A reason: Whole milk and ice cream are high in fat, which can trigger the inflammation of the gallbladder (cholecystitis) and the formation of gallstones. The client should avoid foods that are high in fat, such as fried foods, cheese, butter, cream, and fatty meats.

Choice B reason: Citrus fruit and melon with a salt substitute are not a problem for a client with cholecystitis, unless they have other conditions that require dietary modifications, such as diabetes or kidney disease. The client should eat a balanced diet that includes fruits, vegetables, grains, and lean proteins.

Choice C reason: Pasta with herbal butter and no meat sauce is also acceptable for a client with cholecystitis, as long as the butter is used sparingly and the pasta is not cooked with oil or cheese. The client should limit the intake of refined carbohydrates, such as white bread, rice, and sugar, and choose whole grains instead.

Choice D reason: Canned vegetables with additional table salt are not recommended for a client with cholecystitis, because they are high in sodium, which can increase the risk of fluid retention and hypertension. The client should reduce the intake of salt and processed foods, such as canned soups, sauces, and snacks, and use herbs and spices to flavor the food.

A. Calculate gestation from last menstrual cycle. B. Continue with surgery as scheduled. C. Perform a bedside pregnancy test. D. Notify the surgical team to cancel the surgery.

Correct Answer is C

Explanation

Choice A reason: Calculating gestation from last menstrual cycle is not a reliable way to determine if the client is pregnant, and it is not an urgent intervention that the nurse should implement immediately. The last menstrual cycle may not reflect the actual date of conception, and it may vary depending on the client's cycle length, ovulation time, and other factors. The nurse should use a more accurate and objective method to confirm or rule out pregnancy, such as a urine or blood test.

Choice B reason: Continuing with surgery as scheduled is not a safe or ethical intervention that the nurse should implement immediately, without verifying the client's pregnancy status. Surgery, especially abdominal surgery, can pose significant risks to the client and the fetus, such as bleeding, infection, anesthesia complications, preterm labor, and miscarriage. The nurse should inform the surgical team about the possibility of pregnancy and obtain the client's informed consent before proceeding with surgery.

Choice C reason: Performing a bedside pregnancy test is the most appropriate and timely intervention that the nurse should implement immediately, given the client's situation. A bedside pregnancy test is a simple and quick way to detect the presence of human chorionic gonadotropin (hCG), a hormone produced by the placenta, in the client's urine. A positive result indicates that the client is pregnant, and a negative result indicates that the client is not pregnant. The nurse should perform the test as soon as possible and report the result to the surgical team and the client.

Choice D reason: Notifying the surgical team to cancel the surgery is not a necessary or prudent intervention that the nurse should implement immediately, without confirming the client's pregnancy status. Canceling the surgery may delay the treatment of the client's acute appendicitis, which can lead to serious complications, such as perforation, abscess, peritonitis, and sepsis. The nurse should first perform a bedside pregnancy test and then discuss the risks and benefits of surgery with the surgical team and the client.

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Naxlex Comprehensive Predictor Exams

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

Correct Answer is A

Explanation

While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?

Correct Answer is C

Explanation

A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing food intake, the nurse should include which type of fluid limitation?

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A client who fractured the right femur from a fall at home is placed in skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement?

An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

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