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 B

Explanation

A. Electrolyte imbalances

Administering diluted enteral feedings is not typically done to address electrolyte imbalances. Instead, monitoring the electrolyte levels in the patient's blood and adjusting the content of the enteral formula (such as adjusting the concentration of electrolytes) would be more appropriate.

B. Diarrhea

Administering diluted enteral feedings is a strategy that may be employed to prevent or manage diarrhea. High concentrations of nutrients can overwhelm the gastrointestinal tract, leading to diarrhea. Diluting the formula helps reduce the risk of this complication.

C. Constipation

Administering diluted enteral feedings is not typically done to address constipation. Management of constipation is more commonly achieved through adjustments in fiber intake, fluid intake, and medications as needed.

D. Delayed gastric emptying

Administering diluted enteral feedings is not a standard approach for addressing delayed gastric emptying. Instead, adjustments in the rate of enteral feedings or specific interventions for delayed gastric emptying, such as medication or changes in positioning, would be considered.

A. The stockings are used to reduce pain. B. The stockings prevent varicose veins. C. The stockings prevent venous stasis. D. The stockings replace the need for postoperative leg exercises.

Correct Answer is C

Explanation

A. The stockings are used to reduce pain.

This statement is not accurate. While antiembolism stockings may provide some relief from discomfort and swelling, their primary purpose is to prevent venous stasis and reduce the risk of blood clots, not to directly reduce pain.

B. The stockings prevent varicose veins.

This statement is not entirely accurate. While compression stockings can provide some support to veins, their primary role is in preventing blood clots (venous thromboembolism) rather than preventing varicose veins, which are typically related to venous insufficiency.

C. The stockings prevent venous stasis.

This is the correct answer. Antiembolism stockings are specifically designed to prevent venous stasis, which refers to the slowing or stagnation of blood flow in the veins. They exert gentle pressure on the legs to enhance blood circulation and reduce the risk of blood clots.

D. The stockings replace the need for postoperative leg exercises.

This statement is not accurate. While antiembolism stockings are a preventive measure, they do not replace the need for postoperative leg exercises. Leg exercises are important for promoting circulation, preventing complications such as deep vein thrombosis (DVT), and maintaining overall mobility after surgery.

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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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