The practical nurse (PN) is observing a newly hired unlicensed assistive personnel (UAP) bathing a client who has type 2 diabetes mellitus (DM). The UAP places the client's feet in a wash basin filled with warm soapy water to soak. Which action should the PN take?
Make sure UAP has changed gloves.
Tell the UAP not to soak the feet.
Check the client's feet before soaking.
Test the temperature of the water.
The Correct Answer is B
A. Changing gloves is important for infection control, but in this context, the main issue is with the technique being used for the client's feet.
B. Soaking the feet is not recommended for clients with diabetes due to the risk of skin damage and infection; it is better to wash the feet gently and inspect them regularly.
C. Checking the client’s feet is important but should be done before washing or soaking, and the main concern here is not to soak the feet at all.
D. While testing water temperature is crucial for safe bathing, the more pressing issue here is the method of foot care for a diabetic client, which is not to soak the feet
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A, F, E
Explanation
A. Take the child's pulse
Assessing the pulse is crucial to determine if the child has a heartbeat and to evaluate the effectiveness of CPR. This helps to determine the current cardiovascular status of the child and the urgency of further resuscitation efforts.
F. Determine if the child's airway is clear
Ensuring a clear airway is a priority in any emergency situation. A blocked airway can prevent effective ventilation and oxygenation, which is critical for a child who has experienced a near-drowning incident.
D. Start a peripheral IV line
Starting a peripheral IV line is important for administering fluids and medications that may be necessary for resuscitation and stabilization. It allows for rapid access to the child's circulatory system for necessary interventions.
E. Look for any open wounds
Checking for open wounds is necessary to identify any immediate sources of bleeding or potential infections that need to be addressed. It is part of a thorough initial assessment to ensure comprehensive care for the child.
Correct Answer is []
Explanation
The client’s symptoms—severe chest pain, nausea, dizziness, trembling, and diaphoresis—along with elevated troponin levels, are indicative of a myocardial infarction. Troponin is a cardiac biomarker used to diagnose myocardial infarction, and the client’s symptoms are consistent with this condition.
Actions to Take:
- Use Therapeutic Communication to Build Rapport
Effective therapeutic communication helps the client feel supported and may reduce anxiety and fear related to their condition. This approach can provide a calm environment for the client, which is crucial when managing a myocardial infarction. - Teach Coping Skills
Teaching coping skills can help the client manage anxiety and stress, which are important for recovery from a myocardial infarction. Understanding how to cope with the emotional and psychological aspects of the condition supports overall care and management.
Parameters to Monitor:
- Heart Rhythm
Monitoring heart rhythm is essential to detect any arrhythmias or complications related to myocardial infarction. Changes in heart rhythm can indicate worsening of the condition or response to treatment. - Vital Signs
Monitoring vital signs, including blood pressure and heart rate, is crucial for assessing the client’s hemodynamic status and the effectiveness of treatment. Abnormalities in vital signs can indicate worsening of the myocardial infarction or side effects of medications
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