An ulcerated foot peronet (FP) is to be implemented. The UAPs state they have not yet been educated on this before charging assignments.
What action should the nurse take first?

Send the UAP to be educated on how to care for a foot ulcer.

Advise the UAP to wear gloves when caring for the FP.

Instruct the UAP to start with basic wound care precautions.

Ask the UAP which action they would take first and state why.

Answer and Explanation

The Correct Answer is A

It is important for the UAP to receive proper education and training on how to care for a foot ulcer before being assigned to care for a client with this condition.

Choice B is not correct because advising the UAP to wear gloves when caring for the FP is not the first action the nurse should take.

Choice C is not correct because instructing the UAP to start with basic wound care precautions is not the first action the nurse should take.

Choice D is not correct because asking the UAP which action they would take first and stating why is not the first action the nurse should take.

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Correct Answer is B

Explanation

The assessment of pain intensity by a validated pain scale is a critical initial step, and a patient’s self-reporting is widely considered as the key to effective pain management 1.

According to good practice guidelines, clinicians must accept a patient’s statement, regardless of their own opinions 1.

Choice A is not the answer because asking the client to describe the pain does not provide an objective measure of pain intensity 1.

Choice C is not the answer because identifying effective pain relief measures does not assess the intensity of the client’s pain 1.

Choice D is not the answer because observing body language and movement does not provide an objective measure of pain intensity 1.

A. Places food on the unaffected side of the mouth. B. Raises the head of the bed to 80 degrees. C. Positions the head with the chin tilted slightly downward. D. Allows 30 minutes of rest before feeding.

Correct Answer is B

Explanation

A. Placing food on the unaffected side of the mouth is appropriate for a client who has had a CVA and may have unilateral weakness. This technique helps the client chew and swallow effectively, reducing the risk of aspiration.

B. Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort. This action requires additional teaching.

C. Positioning the head with the chin tilted slightly downward, known as the chin-tuck position, is a recommended strategy to prevent aspiration. This position helps close the airway during swallowing, reducing the risk of food or liquid entering the trachea.

D. Allowing 30 minutes of rest before feeding is appropriate because it ensures the client is not fatigued, which can compromise swallowing ability and increase the risk of aspiration.

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An ulcerated foot peronet (FP) is to be implemented. The UAPs state they have not yet been educated on this before charging assignments. What action should the nurse take first?

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An ulcerated foot peronet (FP) is to be implemented. The UAPs state they have not yet been educated on this before charging assignments.
What action should the nurse take first?