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 A
Explanation
The correct answer is A. Back pain.
Choice A reason: Back pain during a blood transfusion is a classic symptom of a hemolytic transfusion reaction. This type of reaction occurs when the immune system attacks the transfused red blood cells, leading to their destruction. Back pain is considered a more specific and early sign of this reaction.
Choice B reason: Bradycardia, which is a slower than normal heart rate, is not typically associated with hemolytic transfusion reactions. The normal range for an adult’s resting heart rate is between 60 to 100 beats per minute. Bradycardia is usually considered when the heart rate is lower than 60 beats per minute in a resting adult. It can be a sign of a well-trained athlete or can occur as a result of certain medications or heart conditions, but it is not a recognized symptom of a hemolytic transfusion reaction.
Choice C reason: Hypertension, or high blood pressure, is also not a common symptom of a hemolytic transfusion reaction. Normal blood pressure ranges from 90/60 mmHg to 120/80 mmHg. Hypertension is typically defined as having a blood pressure higher than 130/80 mmHg. While hypertension can be a serious condition, it is not indicative of a hemolytic transfusion reaction.
Choice D reason: Chills are a symptom that can be associated with a hemolytic transfusion reaction, often occurring alongside fever and back pain. However, while chills can indicate a reaction, back pain is a more specific symptom that can help differentiate a hemolytic reaction from other types of transfusion reactions.
Correct Answer is C
Explanation
Prealbumin is a protein that is produced by the liver and is used as a marker of nutritional status.
It has a short half-life, so changes in pre albumin levels can reflect recent changes in nutritional status.
Monitoring pre albumin levels can help assess the effectiveness of total parenteral nutrition.
Lipase is an enzyme that is produced by the pancreas and is not used to monitor overall nutritional status.
B) C-reactive protein is a marker of inflammation and is not used to monitor overall nutritional status.
D) Creatinine is a waste product that is produced by muscle metabolism and is not used to monitor overall nutritional status.
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