A nurse is reinforcing teaching for a client who has type 1 diabetes mellitus about foot care. Which of the following client statements should indicate to the nurse an understanding of the instructions?

“I put lotion between my toes.”

“I check my feet every day for sores and bruises.”

“I wear sandals in warm weather.”

“I soak my feet in warm, soapy water every night before I go to bed.”

Answer and Explanation

The Correct Answer is B

Choice A: “I put lotion between my toes.” This is incorrect because putting lotion between the toes can create a moist environment that promotes fungal growth and infection. The client should apply lotion to the tops and botoms of the feet, but avoid the areas between the toes.

Choice B: “I check my feet every day for sores and bruises.” This is correct because checking the feet every day for any signs of injury, infection, or ulceration is an important part of foot care for a client who has diabetes mellitus. The client should also report any problems to the provider and seek prompt treatment.

Choice C: “I wear sandals in warm weather.” This is incorrect because wearing sandals can expose the feet to injury, sunburn, or insect bites. The client should wear closed-toe shoes that fit well and protect the feet from trauma and environmental hazards.

Choice D: “I soak my feet in warm, soapy water every night before I go to bed.” This is incorrect because soaking the feet can cause maceration of the skin and increase the risk of infection. The client should wash the feet with mild soap and warm water, but not soak them. The client should also dry the feet thoroughly, especially between the toes.

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Correct Answer is C

Explanation

Choice A: Thyroxine (T4) level. This is incorrect because T4 is one of the thyroid hormones that is increased in hyperthyroidism. T4 is produced by the thyroid gland and converted to T3 in the tissues. A high level of T4 indicates overactivity of the thyroid gland.1

Choice B: Triiodothyronine (T3) level. This is incorrect because T3 is another thyroid hormone that is increased in hyperthyroidism. T3 is the more active form of thyroid hormone and regulates the metabolism of cells. A high level of T3 indicates overactivity of the thyroid gland.1

Choice C: Thyroid stimulating hormone (TSH) level. This is correct because TSH is a hormone that stimulates the thyroid gland to produce T4 and T3. TSH is produced by the pituitary gland and regulated by a feedback mechanism. When the levels of T4 and T3 are high, the pituitary gland reduces the secretion of TSH to inhibit further production of thyroid hormones. Therefore, a low level of TSH indicates hyperthyroidism.1

Choice D: Glucose level. This is incorrect because glucose level is not directly related to thyroid function. However, hyperthyroidism can aﬀect glucose metabolism and cause increased blood sugar levels due to increased breakdown of glycogen and glucose uptake by cells. Therefore, glucose level may be elevated in some cases of hyperthyroidism, but it is not a specific indicator.

A. Document the color, consistency, and amount of nasogastric drainage. B. Encourage hourly use of an incentive spirometer while awake. C. Irrigate the nasogastric tube every 4 to 8 hr. D. Perform leg exercises every 2 hr.

Correct Answer is ["A","B","D"]

Explanation

Choice A reason: Documenting the color, consistency, and amount of nasogastric drainage is an important action for the nurse to include in the client’s plan of care. This can help monitor the client’s GI function, ﬂuid balance, and response to treatment. The normal color of nasogastric drainage is clear or yellow-green. Abnormal colors include red, brown, or black, which may indicate bleeding.

Choice B reason: Encouraging hourly use of an incentive spirometer while awake is an important action for the nurse to include in the client’s plan of care. This can help prevent respiratory complications, such as atelectasis and pneumonia, which are common after abdominal surgery. An incentive spirometer is a device that helps the client breathe deeply and expand the lungs.

Choice C reason: Irrigating the nasogastric tube every 4 to 8 hr is not an action that the nurse should include in the client’s plan of care. Routine irrigation of nasogastric tubes is not recommended, as it may increase the risk of infection, tube occlusion, or aspiration. Irrigation should only be done when indicated by specific orders or protocols, or when there is evidence of tube blockage.

Choice D reason: Performing leg exercises every 2 hr is an important action for the nurse to include in the client’s plan of care. This can help prevent venous thromboembolism (VTE), which is a serious complication that can occur after surgery due to immobility and hypercoagulability. Leg exercises can improve blood circulation and reduce stasis in the lower extremities.

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A nurse is reinforcing teaching for a client who has type 1 diabetes mellitus about foot care. Which of the following client statements should indicate to the nurse an understanding of the instructions?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who has hyperthyroidism (Graves disease). Which of the following serum laboratory findings should the nurse expect to be below the expected reference range?

Correct Answer is C

Explanation

A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the client’s plan of care? (Select all that apply).

Correct Answer is ["A","B","D"]

Explanation

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