a client with type 2 diabetes mellitus presents to the clinic with a foot ulcer which instruction should the nurse provide to the client to promote he
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Nursing Elites

ATI LPN

ATI PN Adult Medical Surgical 2019

1. A client with type 2 diabetes mellitus presents to the clinic with a foot ulcer. Which instruction should the nurse provide to the client to promote healing of the ulcer?

Correct answer: C

Rationale: The correct answer is C: "Keep the ulcer clean and dry." For clients with diabetes mellitus, it is crucial to maintain foot ulcers clean and dry to prevent infection and promote healing. Moist environments can lead to bacterial growth and delay healing. Applying a heating pad (Choice A) can increase the risk of burns and further damage the ulcer. Wearing tight-fitting shoes (Choice B) can cause friction and pressure on the ulcer, hindering the healing process. Limiting walking (Choice D) excessively can affect circulation and delay healing. Therefore, the nurse should instruct the client to keep the ulcer clean and dry for optimal wound care management.

2. A patient with peptic ulcer disease is prescribed omeprazole. When should the patient take this medication for optimal effectiveness?

Correct answer: C

Rationale: Omeprazole should be taken before meals to reduce stomach acid production and promote healing of the ulcer. Taking it before meals ensures that the medication can inhibit acid secretion when the stomach is most active in producing acid, thereby maximizing its effectiveness in treating peptic ulcer disease.

3. What action should the healthcare provider take to reduce the risk of vesicant extravasation in a client receiving intravenous chemotherapy?

Correct answer: D

Rationale: Monitoring the intravenous site hourly is essential to identify early signs of extravasation, such as swelling or pain, which can help prevent tissue damage. Prompt detection allows for immediate intervention, minimizing the risk of serious complications associated with vesicant extravasation.

4. A client with newly diagnosed diabetes mellitus is being discharged home. Which statement indicates the client understands the instructions about managing blood glucose levels?

Correct answer: B

Rationale: Choice B is the correct answer. Eating a snack when blood glucose is low (70 mg/dl) can help prevent hypoglycemia. It is important for clients with diabetes to manage their blood glucose levels to prevent complications, and consuming a snack when glucose levels drop can help maintain the balance.

5. What action should the nurse take to prevent tracheal tissue damage in a client with a tracheostomy?

Correct answer: C

Rationale: To prevent tracheal tissue damage in a client with a tracheostomy, the nurse should use the minimal leak technique when inflating the cuff. This method helps avoid excessive pressure on the tracheal tissue, thereby reducing the risk of damage. Choice A is incorrect because securing the tracheostomy ties too tightly can cause pressure and tissue damage. Choice B is incorrect as changing the tracheostomy tube daily is not necessary unless there is a specific clinical indication. Choice D is incorrect as cleaning the stoma with hydrogen peroxide can irritate the skin and mucous membranes, potentially leading to damage.

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