Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client’s comfort?

Rub the client’s feet briskly for several minutes.

Obtain a pair of slipper socks for the client.

Increase the client’s oral fluid intake.

Place a moist heating pad under the client’s feet.

Answer and Explanation

The Correct Answer is B

A. Rub the client’s feet briskly for several minutes.

Rubbing the feet briskly may not be appropriate for a client with vascular occlusion. Vigorous rubbing could potentially cause damage to already compromised blood vessels, and the increased friction may not be well-tolerated.

B. Obtain a pair of slipper socks for the client.

Providing slipper socks is a non-invasive and appropriate measure to help keep the client's feet warm. Slipper socks can offer comfort without the need for vigorous interventions or potential harm. They provide insulation and can be easily applied.

C. Increase the client’s oral fluid intake.

While staying well-hydrated is generally important for overall health, increasing oral fluid intake may not directly address the specific issue of cold feet associated with vascular occlusion. It is essential to address the underlying circulatory issue causing the symptom.

D. Place a moist heating pad under the client’s feet.

Applying heat, especially in the form of a moist heating pad, may not be recommended for a client with vascular occlusion. Heat can dilate blood vessels and potentially exacerbate the issue by increasing blood flow to the compromised extremity. It's important to avoid interventions that could worsen the vascular compromise.

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Correct Answer is C

Explanation

A. Assign an assistive personnel to feed the client.

This option involves assigning someone else to feed the client. While it may ensure that the client receives adequate nutrition, it does not promote independence. The client may prefer to feed themselves if given the opportunity.

B. Explain that the tray is here and place the client’s hands on the tray.

While explaining the presence of the tray is helpful, physically placing the client's hands on the tray is a more direct form of assistance. It takes away the opportunity for the client to explore and locate items independently.

C. Describe to the client the location of the food on the tray.

This is the correct choice. Describing the location of the food on the tray allows the client to use their remaining senses, such as touch and hearing, to independently locate and eat their food.

D. Ask the client if she would prefer a liquid diet.

This option is related to dietary preferences but does not directly address the issue of promoting independence in eating. It focuses more on the type of diet rather than the manner in which the client can independently manage their meals.

A. Close the curtains around the client’s bed. B. Close the door of the client’s room. C. Ask family members to leave the room. D. Use a blanket to cover the client.

Correct Answer is A

Explanation

A. Close the curtains around the client’s bed.

Closing the curtains around the client's bed is a practical way to maintain the client's privacy during a bed bath. This action provides a visual barrier, ensuring that the client is shielded from the view of others in the room.

B. Close the door of the client’s room.

Closing the door is another way to enhance privacy, but it may not be as feasible in all situations. Closing the curtains provides immediate visual privacy without necessarily closing off the entire room.

C. Ask family members to leave the room.

This option is appropriate if family members are present and their presence is not essential for the bed bath. Asking them to step out temporarily can enhance the client's privacy.

D. Use a blanket to cover the client.

While using a blanket is a way to cover and provide modesty during the bed bath, closing the curtains is a more direct measure to maintain visual privacy. Blankets can be used as needed during the bed bath process.

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Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client’s comfort?

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