A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan?

Flex the client's feet using pillows.

Support the client's feet with foot boots.

Place a hand roll under the client's heels.

Remove ankle-foot orthotic devices at bedtime.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: "Support the client's feet with foot boots."

Choice A rationale:

Flexing the client's feet using pillows might not be sufficient to prevent foot drop. Foot drop is a condition where the client is unable to dorsiflex their foot, and using pillows alone may not provide adequate support to prevent this condition.

Choice B rationale:

Supporting the client's feet with foot boots is the most appropriate intervention to prevent foot drop due to immobility. Foot boots are specifically designed to hold the foot in a dorsiflexed position, preventing the calf muscles from tightening and causing foot drop.

Choice C rationale:

Placing a hand roll under the client's heels might offer some relief, but it's not the most effective intervention for preventing foot drop. Hand rolls are generally used to prevent footdrop by keeping the ankles in a neutral position, rather than solely supporting the heels.

Choice D rationale:

Removing ankle-foot orthotic devices at bedtime is not recommended if the client is at risk for developing foot drop. Ankle-foot orthotic devices are designed to provide continuous support to the feet and prevent muscle contractures. Removing them at bedtime could compromise the effectiveness of the intervention.

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Correct Answer is C

Explanation

The correct answer is Choice C: Take vitamin D supplements.

Choice A rationale:

Reducing intake of calcium-rich foods would not be a suitable recommendation. Calcium is essential for bone health, and a client with minimal sunlight exposure is at risk of vitamin D deficiency, which affects calcium absorption. Therefore, this choice would worsen the client's situation.

Choice B rationale:

Using sunscreen with an SPF of 8 is unlikely to provide adequate protection against the harmful effects of sunlight. Moreover, the client's issue is vitamin D deficiency due to minimal sunlight exposure, and using sunscreen would further hinder vitamin D synthesis.

Choice C rationale:

Taking vitamin D supplements is the most appropriate intervention. Vitamin D is synthesized in the skin upon exposure to sunlight, and since the client has minimal sunlight exposure, supplements are necessary to prevent vitamin D deficiency. This choice addresses the root cause of the issue.

Choice D rationale:

Using a tanning bed is not recommended for increasing vitamin D levels. Tanning beds emit ultraviolet (UV) radiation, which can increase the risk of skin cancer. Moreover, excessive UV exposure is not a safe or controlled method for addressing vitamin D deficiency.

A. Keep the side holes of the mask closed. B. Ensure the reservoir bag is inflated on expiration. C. Apply petroleum jelly to the client's nostrils. D. Attach a humidifier to the base of the flow meter.

Correct Answer is D

Explanation

The correct answer is **d. Attach a humidifier to the base of the flow meter**.

Choice A rationale:

Keeping the side holes of the mask closed would restrict airflow and prevent the client from receiving the prescribed oxygen concentration. This action would be unsafe and should not be taken.

Choice B rationale:

Ensuring the reservoir bag is inflated on expiration is not necessary for a simple face mask. The reservoir bag is typically used with other oxygen delivery devices, such as a non-rebreather mask, to provide a higher concentration of oxygen. This action is not appropriate for the given scenario.

Choice C rationale:

Applying petroleum jelly to the client's nostrils is not a recommended action. Petroleum jelly can potentially cause irritation and dryness, which could lead to discomfort for the client. This action is not necessary for the safe administration of oxygen.

Choice D rationale:

Attaching a humidifier to the base of the flow meter is the appropriate action to ensure client safety. Humidifying the oxygen can help prevent drying of the client's airway and make the oxygen more comfortable to breathe. This is a recommended step when administering high-flow oxygen via a simple face mask.

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A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is providing care for a client who has minimal exposure to sunlight. Which of the following interventions should the nurse recommend?

Correct Answer is C

Explanation

A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via a simple face mask. Which of the following actions should the nurse take to ensure client safety?

Correct Answer is D

Explanation

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