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 chart by exception system requires nurses to document deviations from the expected or normal findings rather than documenting every single detail.

D All lung zones should have clear vesicular breath sounds. The presence of diminished sounds indicated lung consolidation which can occur in pneumonic processes or pleural effecusion.

A This finding indicates a normal response known as a consensual response, where the left pupil constricts when light is shone into the right eye.

B Active bowel sounds are considered normal and indicate proper gastrointestinal motility.

C Capillary refill is a quick bedside test used to assess peripheral circulation and tissue perfusion. A refill time of 2 seconds is within the normal range (typically 2 seconds or less), indicating adequate perfusion.

A. Positive external place. B. Motivational phrases. C. Emotional reflection. D. Tranquil sounds.

Correct Answer is A

Explanation

A. This technique involves creating vivid mental images of serene and calming environments, allowing the client to mentally escape from discomfort and focus on a peaceful setting. By immersing themselves in this imagined place, clients may experience relaxation and relief from pain.

B. Motivational phrases are statements or affirmations that inspire and encourage the client. While motivational phrases can be incorporated into guided imagery sessions to boost morale and foster positive thinking, they may not be as effective as focusing on a positive external place for managing chronic pain.

C. While emotional reflection can be an important aspect of holistic pain management, it may not be the primary focus during guided imagery sessions aimed at pain relief.

D. While soothing sounds can create a peaceful ambiance and contribute to stress reduction, they are often used as background elements rather than the primary focus of guided imagery for pain management.

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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

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Correct Answer is D

Explanation

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

Correct Answer is A

Explanation

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

The nurse is reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in the client's plan of care? Select all that apply.

A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer. The client is suspected to have a methicillin- resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

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?

The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?