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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Discarding soiled wound care supplies in a trash receptacle outside the client's room is not an appropriate action. The nurse should dispose of contaminated materials in a biohazard container inside the client's room to prevent the spread of infection.
Choice B reason: Administering antibiotic therapy before culturing the client's wound is not an appropriate action. The nurse should obtain a wound culture before starting antibiotic therapy to ensure accurate results and avoid altering the microorganisms present in the wound.
Choice C reason: Instructing visitors to perform hand hygiene for 15 seconds after leaving the client's room is not an appropriate action. The nurse should instruct visitors to perform hand hygiene for at least 20 seconds before and after entering the client's room to reduce the risk of transmitting infection.
Choice D reason: Placing the client in a private room with a private bathroom is an appropriate action. The nurse should implement contact precautions for a client who has an infectious wound with foul-smelling drainage to prevent cross-contamination and protect other clients and staff from exposure.
Correct Answer is D
Explanation
Choice A: This is incorrect because stool being a dark green color is not a finding that the nurse should report to the provider. Stool from an ileostomy can be dark green, brown, or yellow depending on the diet and fluid intake of the client.
Choice B: This is incorrect because stoma being a cherry red color is not a finding that the nurse should report to the provider. Stoma from an ileostomy should be moist and pink or red, indicating adequate blood supply and healing.
Choice C: This is incorrect because stool containing scant red blood is not a finding that the nurse should report to the provider. Stool from an ileostomy can contain small amounts of blood due to irritation or inflammation of the bowel mucosa.
Choice D: This is correct because stoma retracting into the abdominal wall is a finding that the nurse should report to the provider. Stoma from an ileostomy should protrude slightly above the skin level, allowing for proper drainage and appliance fitting. Stoma retraction can indicate ischemia, obstruction, or peritonitis.
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