A nurse is reinforcing teaching about foot care for a client who has diabetes. Which of the following client statements indicates an understanding of the teaching?
I can apply lotion between my toes after showering.
I can wear open-toe shoes.
I should wear cotton socks.
I should round the corners of my toenails when trimming them.
The Correct Answer is C
Choice A: This is incorrect because applying lotion between the toes can create a moist environment that promotes fungal growth and infection. The client should apply lotion to the feet but avoid the areas between the toes.
Choice B: This is incorrect because wearing open-toe shoes can expose the feet to injury and infection. The client should wear well-fitting, closed-toe shoes that protect the feet and prevent pressure ulcers.
Choice C: This is correct because wearing cotton socks can help keep the feet dry and prevent fungal infections. Cotton socks also provide cushioning and reduce friction.
Choice D: This is incorrect because rounding the corners of the toenails can cause ingrown nails, which can lead to infection and ulceration. The client should trim the toenails straight across and file any sharp edges.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
The statement “I will wrap the suction catheters in a clean towel to be used again at a later time” is incorrect. Suction catheters should be disposed of after each use to prevent infection. Reusing catheters, even if wrapped in a clean towel, can introduce bacteria into the tracheostomy site, leading to potential infections.
Choice B Reason:
The statement “I will set the suction pressure dial between 80 and 120” is correct. The recommended suction pressure for adults is typically between 80 and 120 mmHg. This range is sufficient to effectively clear secretions without causing trauma to the tracheal mucosa. Setting the suction pressure within this range ensures safe and effective suctioning.
Choice C Reason:
The statement “I will suction for less than 15 seconds while inserting the suction catheter” is incorrect. Suctioning should be performed intermittently and for no longer than 10-15 seconds at a time. However, suctioning should not occur while inserting the catheter. Suction should be applied only while withdrawing the catheter to minimize trauma to the tracheal mucosa.
Choice D Reason:
The statement “I will suction the mouth before inserting the suction catheter into the tracheostomy” is incorrect. Suctioning the mouth before the tracheostomy can introduce oral bacteria into the tracheostomy site, increasing the risk of infection. The correct procedure is to suction the tracheostomy first and then the mouth if needed.
Correct Answer is B
Explanation
Choice A reason: Passing of flatus is not a reliable indicator of colostomy function, as it can occur even when there is an obstruction or ischemia in the bowel.
Choice B reason: Stoma is pinkish-red is a sign of a healthy and well-perfused colostomy, as it indicates that the blood supply to the bowel segment is adequate and there is no necrosis or infection.
Choice C reason: Tolerating a clear liquid diet is not a specific indicator of colostomy function, as it does not reflect the amount or consistency of the stool output.
Choice D reason: Absent bowel sounds are not a normal finding for a colostomy, as they can indicate a paralytic ileus or a bowel obstruction, which can cause complications such as distension, pain, or perforation.
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