Nurse Raymond is giving instructions to an elderly client on diabetic foot care. Which teaching is not part of foot care?

Correct Answer: C

Rationale: The correct answer is C because washing feet in hot water can lead to burns or skin damage for those with diabetes. A: Proper footwear is essential for preventing foot injuries. B: Trimming toenails straight across helps prevent ingrown nails. D: Wearing shoes on hot surfaces prevents burns or blisters. Overall, C is incorrect due to the potential harm it can cause to diabetic feet.

Correct Answer: C

Rationale: The correct answer is C: Clinical pathways. Clinical pathways are standardized, evidence-based interdisciplinary plans of care used in case management to guide the treatment and management of clients. They outline the expected course of treatment, interventions, and outcomes for specific health conditions. Kardex care plans (A) are outdated paper-based patient information systems, not specifically for interdisciplinary care plans. Computerized plans of care (B) may refer to electronic health records but do not necessarily imply standardized interdisciplinary plans. Student care plans (D) are educational tools for students and not typically used in case management for clients.

Correct Answer: C

Rationale: Elevating the head of the bed is the correct answer because it helps to promote venous drainage, reduce cerebral edema, and decrease intracranial pressure (ICP). By positioning the patient with the head elevated, gravity assists in preventing further increases in ICP. Encouraging fluids may lead to fluid overload and exacerbate cerebral edema. Providing physical therapy and frequent repositioning may increase ICP by causing unnecessary movement and potential strain on the patient's head and neck.

Correct Answer: B

Rationale: The correct answer is B: Clients with metal implants in their body. An MRI uses strong magnetic fields, which can interact with metal implants, causing movement or heating of the metal and potential harm to the client. This could lead to serious injuries or complications during the scan. Overweight clients (choice A), clients over the age of 60 (choice C), and clients with brain tumors (choice D) do not have contraindications for an MRI scan.

Correct Answer: B

Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take because it helps determine the severity of the allergy and how to best proceed with care. By understanding the specific type of reaction the patient experiences, the nurse can implement appropriate precautions and interventions to prevent any adverse reactions during the patient's stay. Choice A is incorrect because placing the patient in isolation is not necessary for a latex allergy. Choice C is incorrect as terminating the interview is premature and does not address the patient's allergy. Choice D is also incorrect as documenting the allergy is important but not the first action to take when assessing a patient's allergic reaction.

Correct Answer: B

Rationale: The correct answer is B: I.V. administration and urinary excretion. Lomustine is typically administered intravenously, allowing for rapid systemic distribution. The drug is metabolized in the liver and excreted primarily through the kidneys, thus the urinary route. This choice is correct as lomustine's pharmacokinetics align with this pattern. A: Oral administration and urinary - While some drugs are administered orally, lomustine is not typically given orally due to poor bioavailability. C: I.V. administration and fecal excretion - Lomustine is not primarily excreted via the feces, making this choice incorrect. D: Oral administration and fecal excretion - Lomustine is not primarily excreted via the feces, making this choice incorrect.

Correct Answer: E

Rationale: I'm sorry, but it seems like the correct answer (E) is missing from the question. Could you please provide the correct answer so that I can provide you with a detailed explanation of why it is correct and summarize why the other choices are incorrect?

Correct Answer: D

Rationale: The correct action for the nurse to take is to notify the physician stat (choice D). Firstly, the patient presents with painful bladder spasms and blood-tinged urine, indicating a potential complication post-TURP. This warrants immediate medical attention to assess for possible bladder injury or hemorrhage. Giving Demerol (choice A) or B&O suppository (choice B) may provide symptomatic relief but does not address the underlying issue. Warming the irrigation solution (choice C) is not a priority in this situation and does not address the potential serious complications. Notifying the physician immediately allows for prompt evaluation and appropriate intervention to address the patient's condition effectively.

Correct Answer: D

Rationale: The correct answer is D: “I will receive parenteral vitamin B12 therapy for the rest of my life.” This statement is correct because pernicious anemia is a lifelong condition requiring ongoing vitamin B12 supplementation. Patients with pernicious anemia lack intrinsic factor, which is needed to absorb vitamin B12 from food. Therefore, they need lifelong B12 therapy to prevent complications such as anemia and neurological damage. Choices A, B, and C are incorrect because they suggest a limited duration of therapy. Pernicious anemia is a chronic condition that necessitates continuous treatment. Choice A implies therapy until signs and symptoms disappear, which may not address the underlying cause of the deficiency. Choice B mentions therapy until vitamin B12 levels normalize, which may not prevent recurrence. Choice C suggests monthly therapy for a fixed period, which may not be sufficient for lifelong management.