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A nurse is educating a patient with Type 2 diabetes mellitus and peripheral neuropathy. What advice should the nurse give?
- A. Shoes should be worn outside the house, but it is fine to be barefoot inside.
- B. Family members can assist with regular foot exams.
- C. Heating pads are useful if used on the lowest setting.
- D. Aching feet may be soaked in lukewarm water for one hour or more.
Correct Answer: B
Rationale: Family members assisting with regular foot exams helps detect early signs of injury or infection, critical for preventing complications in diabetic neuropathy.
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The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?
- A. Brown, rough, greasy, wart-like papules on the face.
- B. Thick skin plaques topped by silvery white scales.
- C. Requires sunglasses because sunlight hurts eyes.
- D. Tenderness upon palpation and generalized erythema.
Correct Answer: D
Rationale: Tenderness and generalized erythema indicate overexposure to PUVA, signaling potential burns or excessive UV exposure.
The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has a fracture of the femur and is bleeding at the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin subcutaneously daily. Which is the priority nursing action?
- A. Notify the healthcare provider of the client's medication history.
- B. Ensure that the potential for bleeding is explained to the client.
- C. Have the client sign the surgical and transfusion permits.
- D. Observe the heparin injection sites for signs of bruising.
Correct Answer: A
Rationale: Notifying the healthcare provider of the client's heparin use is critical as it increases bleeding risk, requiring potential adjustments to the surgical plan or anticoagulation management.
A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?
- A. Explain the need to limit intake of oral fluids to reduce client discomfort.
- B. Teach the client techniques for performing intermittent catheterization.
- C. Remind the client to practice pelvic floor (Kegel) exercises regularly.
- D. Provide a bedside commode for immediate use in the client's room.
Correct Answer: B
Rationale: Intermittent catheterization manages urinary retention effectively in multiple sclerosis, maintaining bladder health.
A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. Which intervention should the nurse implement?
- A. Document the findings.
- B. Elevate the extremity.
- C. Apply gentle pressure.
- D. Assess the client's temperature.
Correct Answer: A
Rationale: A bruit indicates a patent AV graft, a normal finding that should be documented.
An adult client who had a gastric bypass surgery is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are: temperature 38.3° C, heart rate 130 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 100/50 mm Hg. Which intervention is most important for the nurse to include in the client's plan of care?
- A. Monitor skin for breakdown.
- B. Strict intravenous (IV) fluid replacement.
- C. Encourage regular turning.
- D. Assess wound drainage daily.
Correct Answer: B
Rationale: Strict IV fluid replacement is critical to manage hypovolemia and prevent sepsis in suspected anastomosis leakage.