An older adult client, who is insulin-dependent, arrives at the diabetic clinic with concerns of thick, crusty, and long toenails that are piercing the adjacent toes. Which action should the nurse take?

Cut the nails straight across, then soak the feet for 10 minutes in an antibiotic solution.

Check the client’s feet for cuts or injury, then refer to a foot specialist for nail trimming.

Soak the feet in warm water for 5 minutes, then cut the nails straight across.

Advise the client to soften the nails with lotion prior to cutting them.

Answer and Explanation

The Correct Answer is B

Choice A reason: Cutting nails and soaking in antibiotic solution risks infection in insulin-dependent diabetes, where neuropathy impairs sensation and healing. Thick nails may be fungal, needing specialist care. Checking for injuries and referring to a podiatrist ensures safe management, preventing ulcers in high-risk diabetic feet.

Choice B reason: Checking for cuts assesses diabetic foot risk, as neuropathy and poor glycemic control impair healing. Thick nails piercing toes require podiatrist trimming to prevent trauma or infection. Referral ensures expert care, addressing pathophysiological risks of neuropathy and vascular impairment, preventing serious complications like ulcers.

Choice C reason: Soaking and cutting nails is risky in diabetes, as neuropathy increases injury risk, and warm water may introduce infection in unnoticed wounds. Fungal nails need specialist care. Referral to a podiatrist ensures safe trimming, preventing infection in compromised feet, making this action unsafe.

Choice D reason: Advising lotion to soften nails does not mitigate injury risk from trimming thick nails in diabetes. Neuropathy and poor healing increase infection risk from errors. Specialist referral ensures safe nail management, preventing trauma or ulceration, critical in diabetic foot care due to vascular deficits.

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Correct Answer is D

Explanation

Choice A reason: A cathartic is contraindicated, as pain, distension, and absent bowel sounds suggest postoperative ileus or obstruction, where peristalsis is impaired. Cathartics risk perforation. A nasogastric tube decompresses the bowel, addressing gastrointestinal stasis, preventing complications like vomiting or rupture.

Choice B reason: Reducing IV fluids does not address pain, distension, or absent bowel sounds, indicating ileus or obstruction. Fluids maintain hydration, but nasogastric tube insertion relieves bowel pressure from gas and fluid, restoring function, making fluid reduction ineffective for this postoperative complication.

Choice C reason: Advancing to liquids is inappropriate with absent bowel sounds and distension, indicating ileus, risking vomiting or aspiration. A nasogastric tube removes gastric contents, allowing bowel recovery. Oral intake worsens obstruction, making this contraindicated compared to decompression for safe recovery.

Choice D reason: Nasogastric tube insertion is critical for pain, distension, and absent bowel sounds, suggesting postoperative ileus or obstruction. It decompresses the stomach, removing gas and fluid, reducing pressure and preventing perforation. This addresses the pathophysiological basis of impaired motility, ensuring safe postoperative recovery.

A. Encourage oral electrolyte solution intake. B. Contact their healthcare provider immediately. C. Provide a quiet time by holding or rocking the toddler. D. Assist the child to a recumbent position.

Correct Answer is B

Explanation

Choice A reason: Electrolyte solutions address dehydration but are inappropriate for pale, cool, lethargic symptoms in Tetralogy of Fallot (TOF), indicating a hypercyanotic spell from right-to-left shunting. Urgent medical intervention restores oxygenation, making this inadequate compared to addressing the critical hypoxic episode requiring provider attention.

Choice B reason: Pale, cool, lethargy in TOF signals a hypercyanotic spell, where pulmonary stenosis increases right-to-left shunting, causing cyanosis and hypoxia. Contacting the provider ensures rapid interventions (e.g., oxygen, beta-blockers), preventing cerebral hypoxia or cardiac arrest, addressing the urgent pathophysiological crisis effectively.

Choice C reason: Quiet time by holding or rocking may calm the toddler but does not treat hypoxic spells in TOF, where pale, cool symptoms indicate shunting and hypoxia. Delaying medical intervention risks severe hypoxia, making this less critical than contacting the provider for urgent management.

Choice D reason: A recumbent position worsens TOF’s hypercyanotic spell, increasing venous return and shunting, exacerbating hypoxia. Knee-chest positioning reduces shunting. Contacting the provider is urgent to address pale, cool, lethargic symptoms, ensuring interventions to restore oxygenation, making this position contraindicated.

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An older adult client, who is insulin-dependent, arrives at the diabetic clinic with concerns of thick, crusty, and long toenails that are piercing the adjacent toes. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

On the second postoperative day, a client reports increasing abdominal pain. Assessment findings include a distended abdomen with absent bowel sounds. Which intervention should the nurse anticipate implementing?

Correct Answer is D

Explanation

Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

Correct Answer is B

Explanation

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