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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Applying suction while inserting the catheter is incorrect and can cause tissue damage and hypoxia. Suction should only be applied while withdrawing the catheter to prevent injury to the tracheal mucosa.
Choice B rationale
Applying intermittent suction for up to 30 seconds is excessive and can cause hypoxia and trauma to the trachea. The correct duration for intermittent suctioning is 10-15 seconds per pass to minimize these risks.
Choice C rationale
Preoxygenating the client prior to suctioning helps prevent hypoxia by ensuring the client has adequate oxygen reserves during the procedure. This is a standard practice to enhance patient safety during suctioning.
Choice D rationale
Instructing the client to swallow during catheter insertion is inappropriate and can lead to gagging or aspiration. The client should be relaxed and still during insertion to prevent complications.
Correct Answer is D
Explanation
Choice A rationale
Verbal consent alone is not sufficient for invasive procedures like urinary catheter insertion. Documented consent is necessary to ensure legal and ethical compliance.
Choice B rationale
Having another nurse co-sign the consent does not verify the client's explicit agreement to the procedure. It is important that the client’s direct consent is documented.
Choice C rationale
Checking the medical record for a previous consent form may not reflect the client's current willingness. Consent should be obtained fresh to confirm current understanding and agreement.
Choice D rationale
Witnessing the client's signature on a consent form ensures that the client has been informed and agrees to the procedure, fulfilling both legal and ethical requirements.
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