Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?
Obtain a pair of slipper socks for the client.
Increase the client's oral fluid intake.
Rub the client's feet briskly for several minutes.
Place a moist heating pad under the client's feet.
The Correct Answer is A
A. Obtain a pair of slipper socks for the client. Slipper socks can provide warmth without applying direct heat, which is safer for clients with impaired circulation.
B. Increase the client's oral fluid intake. Increasing fluids does not directly address cold feet and may be contraindicated depending on the client’s condition.
C. Rub the client's feet briskly for several minutes. Rubbing can damage skin and tissue in clients with poor circulation and should be avoided.
D. Place a moist heating pad under the client's feet. Heating pads can cause burns and further impair circulation in clients with vascular issues.
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Correct Answer is A
Explanation
A. Shortness of breath while lying down. Shortness of breath when lying down, or orthopnea, is common in left-sided heart failure due to fluid backing up into the lungs, causing pulmonary congestion.
B. Jugular venous distention. Jugular venous distention is more commonly associated with right-sided heart failure due to systemic venous congestion.
C. Right upper quadrant pain. Right upper quadrant pain is associated with liver congestion due to right-sided heart failure, not left-sided heart failure.
D. Pitting edema of the lower legs. Pitting edema is a symptom of right-sided heart failure, as fluid backs up into the peripheral circulation.
Correct Answer is A
Explanation
A. To prevent blood clotting: Aspirin is an antiplatelet agent, and it reduces blood clot formation, which helps prevent further cardiac events after an MI.
B. To reduce inflammation: Although aspirin has anti-inflammatory properties, this is not the primary reason for its use in post-MI clients.
C. To prevent fever: Aspirin can reduce fever, but this is not its purpose in MI prevention.
D. To provide analgesia: Aspirin can relieve pain, but in this context, it is used to prevent blood clotting, not as an analgesic.