A nurse is caring for a client who has diabetic neuropathy of the lower extremities and has a new prescription for a heating pad. The prescription reads, "Apply to the left foot for 20 min." Which of the following actions should the nurse take?

Contact the provider to clarify the prescription.

Complete a Semmes Weinstein monofilament test before applying the heating pad.

Observe the skin 10 min after the start of treatment.

Apply the heating pad as prescribed by the provider.

Answer and Explanation

The Correct Answer is A

Choice A reason: The nurse should contact the provider to clarify the prescription because applying heat to an area with impaired sensation can cause burns or tissue damage. The nurse should also educate the client about the risks of using heat therapy and alternative methods to relieve pain.

Choice B reason: The Semmes Weinstein monofilament test is used to assess the sensation of light touch in clients with peripheral neuropathy. The nurse should perform this test before applying any intervention that could affect the skin integrity, such as heat, cold, or compression.

Choice C reason: Observing the skin 10 min after the start of treatment is not sufficient to prevent complications from heat therapy. The nurse should monitor the skin continuously and check for signs of redness, blisters, or burns.

Choice D reason: Applying the heating pad as prescribed by the provider is not appropriate for a client with diabetic neuropathy of the lower extremities. Heat can increase blood flow and inflammation in the affected area, which can worsen the condition and increase the risk of infection.

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Correct Answer is A

Explanation

The correct answer is A:

Choice A reason:

Replace the unit when the drainage chamber is full. This ensures continuous, effective drainage. A full chamber cannot collect more fluid, risking system compromise and patient safety.

Choice B reason:

Pinning the tubing to the bed sheets is incorrect because it can cause kinks in the tubing, leading to obstruction of drainage and potential complications.

Choice C reason:

Monitoring for at least 150 mL of drainage every hour is not a standard practice. Normal chest tube drainage is variable; excessive drainage, such as 150 mL/hour, could indicate a serious condition like hemorrhage.

Choice D reason:

Clamping the tube routinely for 30 minutes every 8 hours is not recommended. Clamping may be done during tube removal or to check for air leaks but doing so routinely can lead to tension pneumothorax.

A. Delay ambulation until the next day. B. Apply moist heat prior to ambulation. C. Use a continuous passive motion machine. D. Restrict intake of dairy products.

Correct Answer is B

Explanation

Choice A reason: Delaying ambulation until the next day is not an appropriate intervention, as it can cause stiffness, muscle weakness, or joint contractures in the affected knee. The nurse should encourage regular exercise and activity within the client's tolerance level to maintain joint mobility and function.

Choice B reason: Applying moist heat prior to ambulation is an appropriate intervention, as it can reduce pain and inflammation in the affected knee by increasing blood flow and relaxing the muscles and tendons around the joint.

Choice C reason: Using a continuous passive motion machine is not an appropriate intervention for osteoarthritis, as it is mainly used after knee replacement surgery to prevent scar tissue formation and improve range of motion in the new joint.

Choice D reason: Restricting intake of dairy products is not an appropriate intervention for osteoarthritis, as dairy products are good sources of calcium and vitamin D that can support bone health and prevent osteoporosis. The nurse should advise the client to eat a balanced diet that includes fruits, vegetables, whole grains, lean protein, and low-fat dairy products.

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A nurse is caring for a client who has diabetic neuropathy of the lower extremities and has a new prescription for a heating pad. The prescription reads, "Apply to the left foot for 20 min." Which of the following actions should the nurse take?

Nursing Test Bank

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