Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client’s comfort?
Rub the client’s feet briskly for several minutes.
Obtain a pair of slipper socks for the client.
Increase the client’s oral fluid intake.
Place a moist heating pad under the client’s feet.
The Correct Answer is B
A. Rub the client’s feet briskly for several minutes.
Rubbing the feet briskly may not be appropriate for a client with vascular occlusion. Vigorous rubbing could potentially cause damage to already compromised blood vessels, and the increased friction may not be well-tolerated.
B. Obtain a pair of slipper socks for the client.
Providing slipper socks is a non-invasive and appropriate measure to help keep the client's feet warm. Slipper socks can offer comfort without the need for vigorous interventions or potential harm. They provide insulation and can be easily applied.
C. Increase the client’s oral fluid intake.
While staying well-hydrated is generally important for overall health, increasing oral fluid intake may not directly address the specific issue of cold feet associated with vascular occlusion. It is essential to address the underlying circulatory issue causing the symptom.
D. Place a moist heating pad under the client’s feet.
Applying heat, especially in the form of a moist heating pad, may not be recommended for a client with vascular occlusion. Heat can dilate blood vessels and potentially exacerbate the issue by increasing blood flow to the compromised extremity. It's important to avoid interventions that could worsen the vascular compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Limit potassium-rich foods in the diet.
Limiting potassium is not a typical dietary modification for Cushing's disease. Potassium levels are usually affected in conditions such as Addison's disease, where there is a deficiency of cortisol. In Cushing's disease, the focus is more on sodium balance.
B. Decrease sodium intake.
This is the correct choice. Decreasing sodium intake is a dietary modification relevant to individuals with Cushing's disease. Excessive cortisol production can lead to sodium and water retention, and reducing sodium intake helps manage fluid balance.
C. Increase calorie intake.
While weight gain is a common symptom in individuals with Cushing's disease, simply increasing calorie intake may not be the most specific or appropriate dietary modification. Attention to overall dietary balance and specific components like sodium is more relevant.
D. Consume more calories from carbohydrates than protein.
The macronutrient composition of the diet (carbohydrates vs. protein) is not a specific consideration for individuals with Cushing's disease. The focus is more on overall dietary balance and addressing sodium intake.
Correct Answer is B
Explanation
A. Set the pad’s temperature to 42.2° C (108 F).
The specific temperature setting for a heat application should be based on the healthcare provider's prescription and the therapeutic goals. The temperature should be within a safe and therapeutic range.
B. Stop the treatment if the client’s skin becomes red.
This is the correct choice. Redness on the skin during heat application may indicate potential skin irritation or the onset of a burn. Stopping the treatment if redness occurs is crucial to prevent further injury.
C. Leave the pad in place for at least 40 min.
The duration of heat application should also be based on the healthcare provider's prescription and therapeutic goals. Leaving the pad in place for a specific duration is important, but the exact time would depend on the therapeutic plan.
D. Use safety pins to keep the pad in place.
Safety pins should not be used to secure heat applications, as they can pose a risk of injury. Instead, healthcare professionals should use the appropriate securing devices provided with the heat application or follow facility protocols.
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