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44. A nurse is preparing to provide foot care for a client who is ambulatory. Identify the sequence of steps the nurse should follow when performing foot care. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A.

Gently dry the client's feet and areas between the toes with a towel.

B.

Assist the client into a sitting position in a chair.

C.

Soak the client's feet in warm water.

D.

Apply lotion to the client's feet.

E.

Rub callused areas of the client's feet using a washcloth.

Answer and Explanation

The Correct Answer is B,C,E,A,D

  1. Assist the client into a sitting position in a chair. Ensures comfort and stability before starting foot care.
  2. Soak the client's feet in warm water. Softens the skin and makes cleaning easier.
  3.  Rub callused areas of the client's feet using a washcloth. Helps remove dead skin and promotes circulation.
  4. Gently dry the client's feet and areas between the toes with a towel. Prevents moisture buildup, which can lead to fungal infections.
  5. Apply lotion to the client's feet. Moisturizes the skin but should not be applied between the toes to prevent excessive moisture retention and fungal growth.


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Related Questions

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

The first client the nurse should assess is Client 3 (Pulmonary Edema) followed by Client 1 (Hip Fracture).

Rationale:

Client 3 (Pulmonary Edema) – Highest Priority:

    1. Pulmonary edema is a life-threatening condition that can impair oxygenation.
    2. The client has a history of congestive heart failure (CHF) and a chest x-ray confirming pulmonary edema.
    3. Immediate assessment is required to evaluate for respiratory distress, oxygenation status, and potential need for diuretics or oxygen therapy.

Client 1 (Hip Fracture) – Second Priority:

    1. The x-ray confirms a fractured femoral neck, which can cause severe pain, bleeding, and immobility.
    2. The nurse must assess for circulation, sensation, and movement (CSM) of the affected limb and manage pain.
    3. While this is urgent, it is not as immediately life-threatening as pulmonary edema.

Priority Order (Using ABCs & Maslow’s Hierarchy):

  1. Client 3 – Pulmonary Edema (Airway/Breathing concern)
    2. Client 1 – Hip Fracture (Risk for bleeding, pain, mobility issues)
    3. Client 4 – Low Potassium (Risk for cardiac arrhythmias, needs electrolyte management)
    4. Client 6 – Poor Diabetes Control (HbA1c 9%, requires education & glucose monitoring)
    5. Client 5 – Malnutrition (Prealbumin 12 mg/dL, needs nutrition support for wound healing)
    6. Client 2 – Hyperlipidemia (Not an immediate concern, requires long-term management)

Correct Answer is C

Explanation

A. Stroking the lower abdomen. This technique is not a recognized method for stimulating urination.
B. Performing Kegel exercises prior to urination. Kegel exercises strengthen pelvic muscles but do not directly promote urination.
C. Pouring warm water over the perineum. Warm water can stimulate sensory nerves and promote relaxation of the urethral sphincter, helping to initiate urination.
D. Leaning backward when sitting and attempting to urinate. The proper posture for urination is sitting upright or leaning slightly forward, not backward.

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