A nurse is collecting data from a client who has diabetes mellitus.
The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?
Do you have any problems taking care of your feet?
Do you go barefoot at home?
Have you noticed any problems with foot swelling?
Have you had a problem with ingrown toenails?
The Correct Answer is A
Choice A rationale
Asking if there are any problems taking care of feet directly assesses the client’s ability to perform foot self-hygiene. It opens up discussion about specific difficulties the client may face, such as flexibility, vision, or dexterity issues.
Choice B rationale
Asking if the client goes barefoot at home is related to foot safety but does not directly assess their ability to perform foot self-hygiene. It's important for preventing injuries and infections, especially in clients with diabetes.
Choice C rationale
Inquiring about foot swelling helps identify potential complications related to diabetes but does not address the client's ability to perform foot self-care.
Choice D rationale
Asking about problems with ingrown toenails is specific to a common issue in diabetic foot care but does not provide a comprehensive assessment of the client’s ability to maintain foot hygiene.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Reviewing the client's photograph in the medical record is an effective method to ensure accurate identification. This practice aligns with patient safety protocols and minimizes the risk of medication errors by confirming the patient's identity through a visual match with a documented image.
Choice B rationale
Requesting an assistive personnel to identify the client might be unreliable if the personnel is unfamiliar with the client or makes an error. This approach does not provide a secure verification method and could lead to mistakes.
Choice C rationale
Asking the client to state their room number is not reliable since a client with advanced dementia may not remember their room number accurately. This method does not ensure proper identification and can lead to errors.
Choice D rationale
Having the client state their phone number is inappropriate for clients with advanced dementia, who may struggle to recall such information. This method is not a secure or accurate way to verify identity.
Correct Answer is C
Explanation
Choice A rationale
Injecting air into the ampule prior to drawing the medication into a syringe is incorrect because ampules are sealed glass containers, and injecting air could cause the liquid to spill out due to pressure changes.
Choice B rationale
Adding 0.5 mL of diluent to the medication is not appropriate for most medications in ampules unless specifically instructed by the medication guidelines. Ampules typically contain ready-to-use medication.
Choice C rationale
Using a filter needle to aspirate the medication is the correct action. A filter needle is used to prevent any glass particles from being drawn into the syringe, ensuring the medication is safe for administration.
Choice D rationale
Cleansing the tip of the ampule with an alcohol swab after opening is unnecessary because the ampule's contents are sterile and the risk of contamination is minimized if the ampule is handled correctly.
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