A nurse is caring for a client who has diabetic neuropathy of the lower extremities and has a new prescription for a heating pad. The prescription reads, "Apply to the left foot for 20 min." Which of the following actions should the nurse take?

Contact the provider to clarify the prescription.

Complete a Semmes Weinstein monofilament test before applying the heating pad.

Observe the skin 10 min after the start of treatment.

Apply the heating pad as prescribed by the provider.

Answer and Explanation

The Correct Answer is A

Choice A reason: The nurse should contact the provider to clarify the prescription because applying heat to an area with impaired sensation can cause burns or tissue damage. The nurse should also educate the client about the risks of using heat therapy and alternative methods to relieve pain.

Choice B reason: The Semmes Weinstein monofilament test is used to assess the sensation of light touch in clients with peripheral neuropathy. The nurse should perform this test before applying any intervention that could affect the skin integrity, such as heat, cold, or compression.

Choice C reason: Observing the skin 10 min after the start of treatment is not sufficient to prevent complications from heat therapy. The nurse should monitor the skin continuously and check for signs of redness, blisters, or burns.

Choice D reason: Applying the heating pad as prescribed by the provider is not appropriate for a client with diabetic neuropathy of the lower extremities. Heat can increase blood flow and inflammation in the affected area, which can worsen the condition and increase the risk of infection.

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Correct Answer is A

Explanation

Choice A reason: Asking the client if they are having difficulty breathing is the highest priority question, as it can assess the severity of their allergic reaction to penicillin and the risk of anaphylaxis, which is a life-threatening condition that can cause airway obstruction and respiratory failure.

Choice B reason: Taking the client's heart rate is not a question, but an action that can be done after asking the client about their breathing status. The heart rate can indicate the presence of tachycardia or arrhythmia, which are signs of cardiovascular compromise due to an allergic reaction.

Choice C reason: Telling the client that they need to receive diphenhydramine is not a question, but an action that can be done after asking the client about their breathing status. Diphenhydramine is an antihistamine drug that can reduce the symptoms of an allergic reaction, such as itching, swelling, or wheezing.

Choice D reason: Asking the client if they have any allergies to medications is not a high priority question, as it can be done before administering penicillin or after stabilizing the client's condition. Knowing the client's allergy history can help prevent future adverse reactions and guide appropriate treatment choices.Question 42

A. Cover the client with a warm blanket. B. Increase the IV fluid rate. C. Reassure the client. D. Compare the reading to the preoperative value.

Correct Answer is D

Explanation

Choice D: Comparing the reading to the preoperative value is the first action that the nurse should take because it can help determine if the client's blood pressure is normal for them or if it indicates hypotension, which can be a sign of hemorrhage, shock, or infection.

Choice a is not correct because covering the client with a warm blanket is not the first action that the nurse should take, but rather an intervention that can help prevent hypothermia and shivering, which can increase oxygen demand and blood loss.

Choice b is not correct because increasing the IV fluid rate is not the first action that the nurse should take, but rather an intervention that can help restore fluid volume and blood pressure, if indicated by other data and prescribed by the provider.

Choice c is not correct because reassuring the client is not the first action that the nurse should take, but rather an intervention that can help reduce anxiety and stress, which can affect blood pressure and heart rate.

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A nurse is caring for a client who has diabetic neuropathy of the lower extremities and has a new prescription for a heating pad. The prescription reads, "Apply to the left foot for 20 min." Which of the following actions should the nurse take?

Nursing Test Bank

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