a nurse is providing discharge instructions to a client with diabetes mellitus about foot care which statement indicates an understanding of the teach
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A client with diabetes mellitus is receiving discharge instructions about foot care from a nurse. Which statement indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B: 'I will wear shoes at all times.' This statement demonstrates an understanding of foot care for a client with diabetes. Wearing shoes at all times helps protect the feet, reducing the risk of injury and complications such as wounds or infections. Option A is incorrect because soaking feet in hot water can lead to skin dryness and increase the risk of burns or injury for individuals with diabetes. Option C is incorrect as cutting toenails in a rounded shape can cause ingrown toenails and potential infections. Option D is also incorrect as applying lotion between the toes can create a moist environment, increasing the risk of fungal infections.

2. A nurse is monitoring a client who is receiving continuous enteral feedings. What is a sign of intolerance to the feeding?

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Weight gain (Choice A) is not typically a sign of intolerance to enteral feedings but may indicate other health issues. Constipation (Choice C) is not a common sign of feeding intolerance. Decreased heart rate (Choice D) is not typically associated with intolerance to enteral feedings.

3. A nurse is caring for a client who is experiencing fluid volume deficit (FVD). What clinical finding should the nurse expect?

Correct answer: B

Rationale: Increased heart rate is a common sign of fluid volume deficit (FVD) as the body compensates for decreased fluid levels. When a client is experiencing FVD, the body tries to maintain perfusion to vital organs by increasing the heart rate. This compensatory mechanism helps to improve cardiac output and maintain blood pressure. Choices A, C, and D are incorrect because in FVD, hematocrit may be increased due to hemoconcentration, blood pressure tends to decrease as a compensatory response to FVD, and respiratory rate is usually unaffected or may increase due to attempts to maintain oxygenation.

4. A client who is at risk for developing a deep vein thrombosis (DVT) after surgery. What intervention should the nurse implement to reduce this risk?

Correct answer: B

Rationale: The correct intervention to reduce the risk of deep vein thrombosis (DVT) after surgery is to use compression stockings. Compression stockings help prevent DVT by promoting venous return, which reduces the likelihood of blood pooling in the legs and forming clots. Choices A, C, and D are incorrect because avoiding ambulation can actually increase the risk of DVT, using a heating pad does not directly address DVT prevention, and elevating the client's legs on a pillow alone may not provide sufficient compression to prevent DVT.

5. A client is being taught about measures to promote sleep for insomnia. Which client statement indicates understanding?

Correct answer: C

Rationale: The correct answer is C. By reducing fluid intake 2 hours before bedtime, the client can prevent nighttime awakenings to urinate, which promotes better sleep. Napping during the day (choice A) may interfere with nighttime sleep. Drinking caffeine (choice B) can disrupt sleep patterns. Exercising right before bed (choice D) can actually stimulate the body and make it harder to fall asleep.

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