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 D

Explanation

A. Clean the perineum from front to back.

After arranging the sterile items, the next step involves preparing the client for catheter insertion, which includes cleaning the perineum from front to back using appropriate techniques to minimize the risk of infection.

B. Lubricate the catheter.

Following the preparation of the client, the next step involves lubricating the catheter before insertion. Lubrication facilitates the smooth and atraumatic insertion of the catheter.

C. Explain to the client that she will feel temporary discomfort.

Providing information and preparing the client for the procedure is an important aspect, but it typically follows the physical preparation steps. Explaining to the client about potential discomfort should be done before the procedure but after the necessary physical preparations are complete.

D. Arrange the sterile items on the sterile field.

This is the first action to be taken. It involves preparing all the necessary sterile items on a sterile field, ensuring that everything needed for the catheter insertion procedure is organized and ready to maintain aseptic technique.

A. Liver B. Milk C. Beans D. Eggs

Correct Answer is C

Explanation

A. Liver

Liver is high in cholesterol and should be limited in a low-cholesterol diet. It is a rich source of dietary cholesterol.

B. Milk

While milk itself is not particularly high in cholesterol, it contains saturated fat. In a low-cholesterol diet, it is often recommended to choose low-fat or fat-free dairy products to reduce saturated fat intake.

C. Beans

This is the correct choice. Beans are a plant-based protein source that is low in cholesterol. They are high in fiber and contribute to heart-healthy eating.

D. Eggs

Eggs are a source of dietary cholesterol. While current dietary guidelines suggest that moderate egg consumption may be acceptable for many individuals, those following a low-cholesterol diet may need to be mindful of their overall cholesterol intake from various sources.

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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?

Nursing Test Bank

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