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. "I'll use my electric razor for shaving." This is correct as using an electric razor helps prevent cuts, which is important since warfarin increases bleeding risk.
B. "I'll be sure to eat foods with lots of vitamin K." Vitamin K reduces the effectiveness of warfarin; clients should be consistent with their intake of vitamin K to avoid fluctuations in INR.
C. "It's okay to have a couple of glasses of wine with dinner." Alcohol can increase the effect of warfarin and the risk of bleeding. Clients should avoid or limit alcohol intake.
D. "I'll take aspirin for my headaches." Aspirin also has anticoagulant effects and can increase bleeding risk when taken with warfarin.
Correct Answer is D
Explanation
A. Barrel chest. A barrel chest is commonly seen in chronic obstructive pulmonary disease (COPD) rather than mitral valve stenosis.
B. Bradycardia. Bradycardia is not typically associated with mitral valve stenosis, as symptoms often include rapid or irregular heartbeat.
C. Clubbing of the fingers. Clubbing is associated with chronic hypoxia, often due to pulmonary conditions, not specifically with mitral valve stenosis.
D. Heart murmur. Mitral valve stenosis causes turbulent blood flow through the narrowed valve, resulting in a characteristic murmur.