A nurse is preparing a client who has advanced cirrhosis for an abdominal paracentesis. Which of the following actions should the nurse take?

Choice A: “I put lotion between my toes.” This is incorrect because putting lotion between the toes can create a moist environment that promotes fungal growth and infection. The client should apply lotion to the tops and botoms of the feet, but avoid the areas between the toes.

Choice B: “I check my feet every day for sores and bruises.” This is correct because checking the feet every day for any signs of injury, infection, or ulceration is an important part of foot care for a client who has diabetes mellitus. The client should also report any problems to the provider and seek prompt treatment.

Choice C: “I wear sandals in warm weather.” This is incorrect because wearing sandals can expose the feet to injury, sunburn, or insect bites. The client should wear closed-toe shoes that fit well and protect the feet from trauma and environmental hazards.

Choice D: “I soak my feet in warm, soapy water every night before I go to bed.” This is incorrect because soaking the feet can cause maceration of the skin and increase the risk of infection. The client should wash the feet with mild soap and warm water, but not soak them. The client should also dry the feet thoroughly, especially between the toes.

Choice A reason: Providing emotional support is important for a client who has ulcerative colitis, as the condition can affect their quality of life and mental health. However, this is not the priority action for a nurse who is caring for a client who is experiencing an acute exacerbation of ulcerative colitis, as it does not address the immediate physical needs of the client.

Choice B reason: Evaluating fluid and electrolyte levels is the priority action for a nurse who is caring for a client who is experiencing an acute exacerbation of ulcerative colitis, as the client is at risk of dehydration, hypovolemia, and electrolyte imbalances due to diarrhea, vomiting, and poor oral intake. The nurse should monitor the client’s vital signs, urine output, weight, skin turgor, mucous membranes, and laboratory values such as serum sodium, potassium, chloride, bicarbonate, blood urea nitrogen (BUN), and creatinine.

Choice C reason: Promoting physical mobility is beneficial for a client who has ulcerative colitis, as it can help prevent complications such as deep vein thrombosis (DVT), pulmonary embolism (PE), and pressure ulcers. However, this is not the priority action for a nurse who is caring for a client who is experiencing an acute exacerbation of ulcerative colitis, as the client may have abdominal pain, fatigue, and weakness that limit their mobility. The nurse should encourage rest and provide comfort measures such as positioning, heat therapy, and analgesics.

Choice D reason: Reviewing stress factors that can cause disease exacerbation is helpful for a client who has ulcerative colitis, as stress can trigger or worsen inflammation in the bowel. However, this is not the priority action for a nurse who is caring for a client who is experiencing an acute exacerbation of ulcerative colitis, as it does not address the immediate physical needs of the client. The nurse should teach the client about stress management techniques and refer them to appropriate resources such as counseling or support groups.