A nurse is providing instructions about foot care for a client who has peripheral arterial disease.
The nurse should identify which of the following statements by the client indicates an understanding of the teaching.
"I rest in my recliner with my feet elevated for about an hour every afternoon.".
"l apply a lubricating lotion to the cracked areas on the soles of my feet every morning.".
"I soak my feet in hot water before trimming my toenails.".
"I use my heating pad on a low setting to keep my feet warm.".
The Correct Answer is B
The correct answer is: b. “I apply a lubricating lotion to the cracked areas on the soles of my feet every morning.”
Choice A reason: Elevating the feet for long periods is not generally recommended for clients with Peripheral Arterial Disease (PAD). This is because elevation can decrease arterial blood flow to the feet, which is already compromised in PAD. The goal is to promote blood flow to the extremities, and elevation might work against this, especially if done for extended periods.
Choice B reason: Applying a lubricating lotion to the feet, particularly on the soles where the skin can become very dry and cracked, is beneficial for someone with PAD. It helps to maintain skin integrity and prevent skin breakdown, which can lead to serious complications due to the reduced blood flow and healing capacity in PAD.
Choice C reason: Soaking the feet in hot water is not advisable for individuals with PAD. They may have reduced sensation in their feet due to poor circulation, which increases the risk of burns from hot water. Additionally, prolonged soaking can lead to maceration of the skin, making it more susceptible to injury and infection.
Choice D reason: Using a heating pad, even on a low setting, to keep the feet warm is risky for clients with PAD. Due to decreased sensation from poor circulation, there is a danger of burns because the client may not feel how hot the heating pad is. It’s better to wear warm socks or use room temperature control to keep the feet warm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer isChoice D.
Choice A rationale:Checking potassium levels is important in the management of DKA, but it is not the priority intervention.The priority intervention is to restore intravascular volume with fluid resuscitation
Choice B rationale:Bicarbonate infusion is not the priority intervention in the management of DKA.It is used only in severe cases of metabolic acidosis
Choice C rationale:Initiation of a continuous IV insulin infusion is an important intervention in the management of DKA, but it is not the priority intervention.The priority intervention is to restore intravascular volume with fluid resuscitation
Choice D rationale:Administering 0.9% sodium chloride is the priority intervention in the management of DKA.It is used to restore intravascular volume and correct electrolyte imbalances
Correct Answer is D
Explanation
A change in behavior such as agitation and restlessness in a client with a traumatic brain injury can be a sign of increased intracranial pressure.
The nurse should first assess the client’s blood pressure as an increase in blood pressure can be an indicator of increased intracranial pressure.
Motor responses are not the first assessment that should be performed.
Blood glucose is not the first assessment that should be performed.
Urinary output is not the first assessment that should be performed.
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