A nurse is reinforcing teaching about preventing long-term complications of retinopathy and neuropathy with an older adult client who has diabetes mellitus. Which of the following actions is the most important for the nurse to include in the teaching?
“Wear closed-toed shoes daily.”
“Maintain stable blood glucose levels.”
“Plan to have an eye examination once per year.”
“Examine your feet carefully every day.”
The Correct Answer is B
Choice A reason: Wearing closed-toed shoes daily is a good practice for people with diabetes, as it can protect the feet from injuries and infections. However, it is not the most important action for preventing long-term complications of retinopathy and neuropathy. These complications are mainly caused by high blood glucose levels that damage the blood vessels and nerves in the eyes and feet.
Choice B reason: Maintaining stable blood glucose levels is the most important action for preventing long-term complications of retinopathy and neuropathy. High blood glucose levels can cause oxidative stress, inflammation, and endothelial dysfunction, which impair the blood flow and oxygen delivery to the eyes and feet. This can lead to nerve damage (neuropathy) and vision loss (retinopathy) over time. Keeping blood glucose levels within the target range can reduce the risk of these complications and slow down their progression if they already exist.
Choice C reason: Planning to have an eye examination once per year is a recommended action for people with diabetes, as it can help detect and treat retinopathy before it causes irreversible damage to the retina. However, it is not the most important action for preventing long-term complications of retinopathy and neuropathy. Eye examinations cannot prevent retinopathy from occurring or worsening; they can only monitor its status and provide appropriate interventions.
Choice D reason: Examining your feet carefully every day is another recommended action for people with diabetes, as it can help identify and treat any signs of neuropathy, such as numbness, tingling, pain, or ulcers. However, it is not the most important action for preventing long-term complications of retinopathy and neuropathy. Foot examinations cannot prevent neuropathy from occurring or worsening; they can only monitor its status and provide appropriate care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Weigh the client weekly. This is incorrect because the client receiving PN should be weighed daily, not weekly, to monitor fluid balance and nutritional status. The nurse should also measure the client’s intake and output, blood glucose, electrolytes, and other laboratory values daily.
Choice B: Reduce the rate of the solution gradually to discontinue. This is correct because the nurse should taper off the PN solution slowly to prevent rebound hypoglycemia, which can occur when the high concentration of glucose in the PN solution is abruptly stopped. The nurse should follow the provider’s orders or the facility’s protocol for reducing and discontinuing PN.
Choice C: Remove solution from refrigerator 2 hr before infusion. This is incorrect because the nurse should remove the PN solution from the refrigerator 30 to 60 minutes before infusion, not 2 hr, to allow it to reach room temperature. Infusing a cold solution can cause discomfort, vasoconstriction, and impaired absorption of nutrients.
Choice D: Shake the solution before hanging if there is a layer of fat present on the top. This is incorrect because the nurse should not shake the PN solution at all, as this can cause fat emulsion droplets to coalesce and form large particles that can clog the filter or cause embolism. The nurse should gently invert or roll the PN solution container to mix it if there is any separation of components.
Correct Answer is B
Explanation
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today