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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Use a blow dryer on a moderate heat setting to dry the cast after showering.

This is not recommended as using a blow dryer on a cast can cause burns. Instead, the cast should be allowed to air-dry or be dried with a fan.

B. Use a cotton swab to relieve itching under the cast.

Inserting objects, including cotton swabs, under the cast can lead to complications such as infection or skin damage. It is not recommended to insert anything into the cast.

C. Report any worsening or unrelieved pain.

This is the correct instruction. Persistent or increasing pain can indicate complications such as swelling, infection, or neurovascular compromise. It is important for the client to promptly report any changes in pain to healthcare providers.

D. Avoid moving the affected leg.

While it's important to limit movement to allow for proper healing, complete immobilization can lead to joint stiffness and muscle atrophy. Gentle range-of-motion exercises for non-weight-bearing areas may be encouraged, but any specific movement instructions should be provided by the healthcare provider. If movement causes significant pain or discomfort, the client should consult the healthcare provider.

A. “I’ll apply ice to my ankle for 20 minutes every hour.” B. “I’ll rewrap my ankle starting from the knee down.” C. “I’ll walk on my ankle for 10 minutes every hour.” D. “I’ll put a heating pad on my ankle at bedtime tonight.”

Correct Answer is A

Explanation

A. "I’ll apply ice to my ankle for 20 minutes every hour."

This is the correct choice. Applying ice for a specified duration (20 minutes) every hour is a standard recommendation for managing swelling and pain associated with an ankle sprain. It helps reduce inflammation and provides relief.

B. "I’ll rewrap my ankle starting from the knee down."

This statement indicates a misunderstanding. When rewrapping an ankle, it should be done from the bottom (proximal) to the top (distal) to provide proper compression. Starting from the knee down is not the correct technique.

C. "I’ll walk on my ankle for 10 minutes every hour."

This statement may indicate a misunderstanding or potential for harm. Immediate weight-bearing or walking on an injured ankle, especially after a sprain, is generally not recommended. Rest is often a key component of initial management.

D. "I’ll put a heating pad on my ankle at bedtime tonight."

This statement may indicate a misunderstanding. Heat is not typically recommended in the initial stages of treating an acute injury like an ankle sprain, as it may increase inflammation. Ice (cold therapy) is usually the preferred modality early on to reduce swelling and pain.

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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?

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