A nurse is collecting data from a client who has diabetes mellitus.
The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?
Do you have any problems taking care of your feet?
Do you go barefoot at home?
Have you noticed any problems with foot swelling?
Have you had a problem with ingrown toenails?
The Correct Answer is A
Choice A rationale
Asking if there are any problems taking care of feet directly assesses the client’s ability to perform foot self-hygiene. It opens up discussion about specific difficulties the client may face, such as flexibility, vision, or dexterity issues.
Choice B rationale
Asking if the client goes barefoot at home is related to foot safety but does not directly assess their ability to perform foot self-hygiene. It's important for preventing injuries and infections, especially in clients with diabetes.
Choice C rationale
Inquiring about foot swelling helps identify potential complications related to diabetes but does not address the client's ability to perform foot self-care.
Choice D rationale
Asking about problems with ingrown toenails is specific to a common issue in diabetic foot care but does not provide a comprehensive assessment of the client’s ability to maintain foot hygiene.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
Padding bony prominences helps prevent skin breakdown and pressure ulcers, which are critical considerations when using restraints to avoid additional complications for the client.
Choice B rationale
Tying restraints to the bed rail is unsafe because it can lead to injury if the bed rail is moved. Restraints should be tied to the bed frame to prevent accidental harm.
Choice C rationale
Using a square knot for restraints is inappropriate as it is difficult to untie quickly in an emergency. Quick-release knots are recommended for safety and efficiency.
Choice D rationale
Observing the client's skin integrity every 2 hours is essential to detect early signs of skin breakdown and take preventive actions to ensure the client's comfort and safety.
Choice E rationale
Ensuring that two fingers can fit between the restraint and the client ensures that the restraint is not too tight, allowing for circulation and reducing the risk of injury.
Correct Answer is D
Explanation
Choice A rationale
While checking recent medication administration is important, it is not the immediate priority when a client is experiencing shortness of breath. Immediate actions should focus on assessing and improving the client's oxygenation status.
Choice B rationale
Reviewing the client’s most recent SaO2 level is useful, but not the first action to take when there is an immediate concern for the client’s oxygenation. Addressing the current low SaO2 level takes precedence.
Choice C rationale
Notifying the charge nurse is necessary, but the nurse should first attempt to quickly re-evaluate the client’s condition and try simple interventions to improve oxygenation, such as having the client cough and clear their throat.
Choice D rationale
Rechecking the SaO2 level after having the client cough and clear their throat is the appropriate first action. This can help determine if the low SaO2 reading is due to a temporary obstruction, such as mucus, and allows for a more accurate assessment of the client's respiratory status. .
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