A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply)
"Alternate the shoes you wear each day."
"Apply synthetic fabric socks."
"Wear open-toe shoes"
"Wash your feet daily with warm water and soap”
"Soak your feet for 1 hour each day."
Correct Answer : A,B,D
Rationale:
A. "Alternate the shoes you wear each day.": Rotating shoes helps prevent pressure points and reduces the risk of skin breakdown or foot ulcers, which is important for clients with diabetes who have impaired circulation and sensation.
B. "Apply synthetic fabric socks.": Synthetic or moisture-wicking socks help keep feet dry and prevent fungal infections, a common concern in clients with diabetes. Cotton or synthetic blends are preferred over thick wool or socks that retain moisture.
C. "Wear open-toe shoes": Open-toe shoes increase the risk of injury, infection, and trauma, which can lead to serious complications in diabetic clients. Closed, well-fitting shoes provide protection and support.
D. "Wash your feet daily with warm water and soap": Daily washing and gentle drying of the feet helps maintain hygiene, prevents infection, and allows early detection of cuts, cracks, or sores. Warm, not hot, water prevents burns in clients with neuropathy.
E. "Soak your feet for 1 hour each day.": Prolonged soaking can cause skin maceration, increasing the risk of infection and breakdown. Soaking is generally discouraged for clients with diabetes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Assign the AP to ask the client if she has taken her antidiabetic medication today: Asking about medication adherence is part of assessment and requires clinical judgment. Delegating this task to an AP is inappropriate because it involves interpreting client responses and making clinical decisions.
B. Determine if the AP has the skills to perform the test: Before delegating any task, the nurse must verify that the AP is competent and trained to perform the procedure safely. Ensuring skill competency protects the client from harm and aligns with the nurse’s responsibility for delegation.
C. Have the AP check the medical record for prior blood glucose test results: Reviewing medical records and interpreting trends involves clinical judgment and falls outside the typical scope of practice for an AP. This task should remain with the licensed nurse.
D. Help the AP perform the blood glucose test: Assisting the AP is not necessary if the AP is competent and has been properly trained. The nurse’s role is to delegate appropriately, supervise as needed, and ensure safe completion, rather than performing the task alongside the AP.
Correct Answer is C
Explanation
Rationale:
A. Inform the transferring agency of the client's condition: While notifying the transferring facility may be part of documentation or reporting, it does not directly address suspicions of abuse. The priority is to gather accurate information from the client in a safe and confidential manner before reporting.
B. Notify risk management: Risk management may be involved in internal investigation processes, but contacting them is not the first step when abuse is suspected. Immediate priority is assessing the client’s safety and obtaining information about the injuries.
C. Privately interview the client about the injuries: Conducting a private, nonjudgmental interview allows the nurse to gather direct information about the cause of the injuries without influence or intimidation from others. This is a critical first step in identifying potential elder abuse, ensuring the client’s safety, and providing evidence for appropriate reporting.
D. Contact the family regarding the client's condition: Contacting family members before assessing the client can compromise the investigation, particularly if family members are potential perpetrators. Privacy and safety of the client must be prioritized before involving others.
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