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A client with diabetes mellitus is being taught about the importance of foot care by a nurse. Which instruction should the nurse include?
- A. Cut toenails straight across
- B. Wear shoes at all times
- C. Soak feet in hot water daily
- D. Apply lotion between the toes
Correct Answer: B
Rationale: The correct answer is B: 'Wear shoes at all times.' Clients with diabetes are at a higher risk of foot complications due to poor circulation and nerve damage. Wearing shoes at all times helps protect their feet from injuries. Choice A is incorrect because toenails should be cut straight across to prevent ingrown toenails. Choice C is incorrect as soaking feet in hot water can lead to burns or skin damage, especially for those with diabetes who may have reduced sensation. Choice D is incorrect because applying lotion between the toes can create a moist environment, increasing the risk of fungal infections.
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A client is found on the floor experiencing a seizure. What is the nurse's priority action?
- A. Apply oxygen
- B. Place the client on their side
- C. Administer an anticonvulsant
- D. Notify the provider
Correct Answer: B
Rationale: The nurse's priority action when finding a client experiencing a seizure is to place the client on their side. This action helps maintain an open airway and prevents aspiration, which is crucial during a seizure. Applying oxygen may be necessary after ensuring a patent airway, while administering an anticonvulsant is not within the nurse's scope of practice during an acute seizure. Notifying the provider can be done after ensuring the client's immediate safety.
A client with a new diagnosis of diabetes mellitus needs instruction on foot care. What advice should the nurse provide?
- A. Soak feet in warm water daily
- B. Wear shoes at all times
- C. Cut toenails in a rounded shape
- D. Inspect the feet weekly
Correct Answer: B
Rationale: The correct answer is B: 'Wear shoes at all times.' This instruction is crucial for clients with diabetes as it helps protect the feet from potential injuries. Choice A of soaking feet in warm water daily can lead to skin issues and should be avoided. Cutting toenails in a rounded shape, as mentioned in choice C, can increase the risk of ingrown toenails. While inspecting the feet weekly, as in choice D, is important, wearing shoes at all times is a more preventative measure to avoid foot injuries in diabetic clients.
A nurse is caring for a client who has dementia and frequently tries to get out of bed. What actions should the nurse take? (Select all that apply)
- A. Turn off the bed alarm
- B. Use physical restraints
- C. Maintain the bed in the lowest position
- D. Apply a vest restraint
Correct Answer: C
Rationale: Maintaining the bed in the lowest position is an appropriate action when caring for a client with dementia who tries to get out of bed. This helps reduce the risk of falls and ensures the client's safety. Turning off the bed alarm (Choice A) is not advisable as it can be a safety measure to alert the staff when the client tries to get out of bed. Using physical restraints (Choice B) and applying a vest restraint (Choice D) should be avoided as they can lead to physical and psychological harm, reduce mobility, and compromise the client's dignity.
A nurse is reviewing a client's health history and identifies a history of pressure injuries. What intervention should the nurse include in the plan of care?
- A. Reposition the client every 4 hours
- B. Apply a moisture-retentive dressing
- C. Apply a heating pad to the site
- D. Keep the client on bedrest
Correct Answer: B
Rationale: The correct intervention for a client with pressure injuries is to apply a moisture-retentive dressing. This type of dressing helps create a moist wound environment, which is conducive to healing. Repositioning the client every 4 hours is important to prevent further pressure injuries, but it is not the primary intervention for existing pressure injuries. Applying a heating pad to the site can increase the risk of tissue damage and is contraindicated for pressure injuries. Keeping the client on bedrest can lead to further complications and delayed healing of pressure injuries.
A nurse is caring for a client who reports a decrease in the effectiveness of their arthritis medication. What factor should the nurse identify as contributing to this decrease?
- A. Improved mobility
- B. Bowel inflammation
- C. Long-term use of the medication
- D. Frequent dehydration
Correct Answer: B
Rationale: The correct answer is B: Bowel inflammation. Bowel inflammation can decrease the absorption of medications, reducing their effectiveness. Improved mobility (choice A) would generally not contribute to a decrease in medication effectiveness. Long-term use of the medication (choice C) may lead to tolerance but would not directly cause a decrease in effectiveness. Frequent dehydration (choice D) can affect overall health but is not a direct factor in the medication's effectiveness for arthritis.