The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry them. While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?

On dorsal surfaces.

Over the heels.

Around the ankles.

Between the toes.

Answer and Explanation

The Correct Answer is D

D. Thoroughly drying between the toes is essential for preventing moisture buildup, which can contribute to the development of fungal infections such as athlete's foot. In a client with diminished circulation in the lower extremities, ensuring proper drying between the toes becomes even more critical to reduce the risk of skin breakdown and infection.

A, B, C- drying the dorsum, heels and ankle regions is important to prevent maceration of skin but they are not the areas commonly affected by infection in cases of compromised circulation.

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Correct Answer is D

Explanation

D. This area is commonly used for LMWH injections due to its high vascularity and absorption rate. Injecting at least 2 inches away from the umbilicus helps minimize the risk of injury to the umbilical vessels and ensures proper absorption of the medication.

A. Massaging the injection site is not recommended after administering LMWH because it can increase the risk of bruising, bleeding, or tissue damage.

B. LMWH injections are typically administered in the abdomen, with sites rotated within the same area. While rotating between the abdomen and gluteal areas may be appropriate for some medications, LMWH is generally administered in the abdomen only.

C. If you expel the air bubbles before injecting, you might inadvertently expel a small amount of insulin along with the air. This could result in receiving less insulin than intended.

A. Switch to a non-rebreather mask. B. Verify placement of pulse oximeter. C. Increase the oxygen to 3 L/minute. D. Remove nasal cannula.

Correct Answer is B

Explanation

B. When the oxygen saturation is lower than expected, the nurse's first action should be to verify the accuracy of the reading by ensuring the proper placement and functioning of the pulse oximeter. This involves checking that the pulse oximeter probe is securely attached to the client's finger or other appropriate site and that there are no obstructions or interference affecting the reading.

A. A non-rebreather mask delivers higher concentrations of oxygen compared to a nasal cannula and is typically used when a client requires higher levels of oxygen supplementation. However, switching to a non-rebreather mask may not be appropriate without further assessment.

C. Increasing the oxygen flow rate to 3 L/minute would deliver a higher concentration of oxygen to the client, potentially improving oxygen saturation. However, increasing the oxygen flow should be done cautiously and based on clinical assessment to avoid oxygen toxicity.

D. Removing the nasal cannula would deprive the client of supplemental oxygen, which may not be appropriate if the client's oxygen saturation is already low. Oxygen supplementation is typically provided to improve oxygenation and support vital organ function.

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The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry them. While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?

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Naxlex Comprehensive Predictor Exams

The nurse is teaching the client to self-administer a dose of low-molecular-weight heparin (LMWH) SUBQ: Which instruction should the nurse include?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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