The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?
Self-care deficit.
Impaired physical mobility.
Risk for infection.
Risk for impaired skin integrity.
The Correct Answer is D
Choice A rationale
While a self-care deficit may be a concern for clients with neuropathy, it is not the primary issue related to foot care. The priority is to prevent skin breakdown and injuries that can lead to more serious complications.
Choice B rationale
Impaired physical mobility is a common issue for clients with neuropathy, but it is not the primary concern for foot care. The focus should be on preventing skin breakdown and injuries.
Choice C rationale
Risk for infection is an important consideration, but it is secondary to the risk of impaired skin integrity. Preventing skin breakdown and injuries is the first step in reducing the risk of infection.
Choice D rationale
Risk for impaired skin integrity is the priority for promoting foot care in clients with neuropathy. Neuropathy can compromise the ability to detect injuries or wounds on the feet, leading to unnoticed wounds that can become infected and cause serious complications.
Preventing skin breakdown and injuries is crucial for maintaining foot health.
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Correct Answer is B
Explanation
Choice A rationale
Advising the UAP to hold the thermometer securely in place for a full three minutes is unnecessary and may cause discomfort to the client. Tympanic thermometers typically provide rapid temperature readings within a few seconds.
Choice B rationale
Positive reinforcement is important for encouraging and motivating staff, it should be used appropriately. In this case, the UAP is performing the procedure correctly.
Choice C rationale
Demonstrating the correct technique for pulling the client’s auricle down and back is incorrect because the UAP is using the correct technique. For adults, the auricle should be pulled up and back.
Choice D rationale
Reminding the UAP to lubricate the thermometer before gently inserting it in the ear is not necessary for tympanic thermometers. The primary issue in this scenario is the incorrect technique for positioning the client’s auricle, so reminding about lubrication is not the most relevant intervention.
Correct Answer is C
Explanation
Choice A rationale
Removing dentures or other oral appliances is not the most critical intervention for a client with severe obstructive sleep apnea (OSA) who has received an opioid analgesic. The priority is to ensure airway patency.
Choice B rationale
Elevating the head of the bed to a 45-degree angle can help improve airway patency but is not as effective as applying the positive airway pressure device.
Choice C rationale
Applying the client’s positive airway pressure device (CPAP or BiPAP) is the most important intervention because it directly maintains airway patency and prevents respiratory compromise, which is crucial for a client with severe OSA2.
Choice D rationale
Putting and locking the side rails in place is important for safety but does not address the critical need to maintain airway patency in a client with severe OSA.