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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?

A.

Self-care deficit.

B.

Impaired physical mobility.

C.

Risk for infection.

D.

Risk for impaired skin integrity.

Answer and Explanation

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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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Giving the client a hug may not be appropriate in a professional setting and could be perceived as crossing personal boundaries.

Choice B rationale

While touching the client’s forearm, asking “Would you like to talk about it?” is a compassionate and supportive response. It shows empathy and provides the client with an opportunity to express their feelings.

Choice C rationale

Apologizing for disturbing the client and offering to wait until later may not address the client’s immediate emotional needs.

Choice D rationale

Stating that it is a bad time and offering to come back later may not provide the client with the support they need in the moment.

Correct Answer is D

Explanation

Choice A rationale

Double-checking all dosage calculations is a crucial step in preventing medication errors. This process involves verifying the calculations to ensure the correct dose is administered. However, while important, it is not the most effective technique on its own. It must be combined with other strategies to ensure comprehensive error prevention.

Choice B rationale

Identifying unusually large or small doses is essential in preventing medication errors. This involves recognizing doses that fall outside the typical range for a given medication and patient population. However, this technique alone does not address other potential errors, such as patient misidentification or incorrect medication administration.

Choice C rationale

Comparing the medication label to the order is a fundamental step in preventing medication errors. This process ensures that the correct medication is being administered as per the physician’s order. However, this technique alone does not address other potential errors, such as incorrect dosage calculations or patient misidentification.

Choice D rationale

Using at least two client identifiers before administering a dose is the most effective technique in preventing medication errors. This process ensures that the correct patient is receiving the correct medication. It addresses the critical issue of patient misidentification, which is a common cause of medication errors. By confirming the patient’s identity using two identifiers, such as name and date of birth, the risk of administering medication to the wrong patient is significantly reduced.

Choice E rationale

Involving and educating clients in medication administration is an important strategy in preventing medication errors. Educated clients are more likely to understand their medication regimen and recognize potential errors. However, this technique alone does not address other potential errors, such as incorrect dosage calculations or patient misidentification.

Choice F rationale

Documenting all medication in the electronic record as soon as it is given is a crucial step in preventing medication errors. This process ensures that there is an accurate and up-to-date record of all medications administered. However, this technique alone does not address other potential errors, such as incorrect dosage calculations or patient misidentification.

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