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

A. Erythema (redness) and serosanguineous exudate (clear to blood-tinged fluid) are typical findings in the early stages of wound healing, especially within the first few days post-surgery. However, one week post-surgery, these signs should begin to decrease as the wound progresses through the inflammatory phase of healing.

B. Eschar (dry, black, or brown necrotic tissue) and slough (yellow or white soft tissue) are indicative of non-viable tissue and delayed wound healing.

C. Beefy red granulation tissue is a positive sign of healing. It indicates new tissue formation, which is essential for the healing process. Granulation tissue is typically moist, and its presence suggests that the wound is progressing well towards healing.

D.This indicates that the edges of the incision are properly closed and healing as expected.

A. Places food on the unaffected side of the mouth. B. Allows 30 minutes of rest before feeding. C. Raises the head of the bed to 60 degrees. D. Positions the head with the chin tilted slightly downward.

Correct Answer is B

Explanation

B. Allowing a period of rest before feeding is not a standard practice for individuals at risk for aspiration and may not address the underlying issues related to dysphagia or aspiration risk. A, C, D- are appropriate positions during feeding for clients with stroke to prevent choking/aspiration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

Correct Answer is D

Explanation

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Correct Answer is B

Explanation

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