The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry them. While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?

On dorsal surfaces.

Over the heels.

Around the ankles.

Between the toes.

Answer and Explanation

The Correct Answer is D

D. Thoroughly drying between the toes is essential for preventing moisture buildup, which can contribute to the development of fungal infections such as athlete's foot. In a client with diminished circulation in the lower extremities, ensuring proper drying between the toes becomes even more critical to reduce the risk of skin breakdown and infection.

A, B, C- drying the dorsum, heels and ankle regions is important to prevent maceration of skin but they are not the areas commonly affected by infection in cases of compromised circulation.

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Correct Answer is D

Explanation

D. The short, rattling, high-pitched sounds heard in the lower lobes of the client with pneumonia are indicative of crackles. Crackles are abnormal respiratory sounds that occur when air moves through fluid or mucus in the small airways or alveoli.

A. Stridor refers to a high-pitched, wheezing sound that occurs during inspiration or expiration and is typically associated with upper airway obstruction, such as in conditions like croup or foreign body aspiration.

B. Pleural rub refers to a grating or rubbing sound heard on auscultation that occurs when inflamed pleural surfaces rub against each other during respiration. It is commonly heard in conditions such as pleurisy or pleural effusion.

C. Wheezing refers to a high-pitched, musical sound heard during expiration that is typically associated with narrowing or obstruction of the airways, as seen in conditions like asthma or chronic obstructive pulmonary disease (COPD).

A. Elevate the head of bed 45 degrees. B. Irrigate the nasogastric tube with water. C. Perform oropharyngeal suctioning. D. Review the advanced directive document.

Correct Answer is A

Explanation

A. Elevate the head of bed 45 degrees is the correct action because it helps clear the airway and reduce vomiting.

B. Irrigating the nasogastric tube with water is not the most appropriate action in this scenario. While it may help clear any obstructions in the tube itself, it does not directly address the immediate concern of clearing the airway of vomitus to prevent aspiration.

C. While suctioning is an effective intervention for clearing the airway, if the client is in a choking situation, establishing a safe position (like elevating the head of the bed) is a priority before any suctioning is performed.

D. Reviewing the advance directive document is important for understanding the client's wishes regarding medical interventions, including resuscitation and life-sustaining treatments.

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The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry them. While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse hears short, rattling, high-pitched sounds in the lower lobes of a client with pneumonia. Which finding should the nurse document?

Correct Answer is D

Explanation

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

Correct Answer is A

Explanation

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