Getting Ready for Certification

Preparing for certification in foot and nail care requires mastery of core competencies that align with safe, evidence-based clinical practice. One key domain focuses on the ability to instruct patients and caregivers on risk factors and foot care guidelines. This area is essential not only for certification examination readiness but also for optimizing patient outcomes and reducing preventable complications. Patients with diabetes mellitus are at high risk for lower extremity amputations, higher health care costs, and lower health-related quality of life, and with many complications that are preventable by regular medical provider examination and performing routine foot care. Patient and caregiver education is a cornerstone of lower extremity health. Certified Foot Care Nurses (CFCNs) play a critical role in fostering patient autonomy and empowering caregivers through tailored, health literate, linguistic, and culturally relevant instruction. Additionally, foot care nurses are key in reducing complications and costs related to lower extremity and nail disease complications. When preparing for the certification examination, candidates should review risk factors, foot care guidelines, and teaching strategies. Conducting a thorough assessment first will provide the CFCN with the proper education on prevention of risk and minimizing complications. Foot and nail disorders significantly increase morbidity and mortality if left untreated.1 Comorbid conditions such as diabetes mellitus, atherosclerosis, hypertension, kidney or heart disease often contribute to lower extremity complications. Systemic disorders, such as arthritis, gout, Raynaud disease, and other vascular conditions, are also frequently associated with foot health concerns.2 In older adults, declines in sweat gland function lead to xerosis (dry skin), which can progress to fissures or keratotic lesions such as calluses. Calluses not only cause discomfort; they also increase the risk of falls.3 In patients with diabetes mellitus, neuropathy, or arterial disease, reduced sensation further heightens the risk, as unrecognized dryness and callus formation, combined with friction and shear, can lead to ulcer development. Additionally, inadequate hygiene practices, such as failing to dry feet thoroughly after washing or not changing socks daily, can contribute to common infections such as tinea pedis (athlete’s foot). Conditions such as vision loss and obesity can impair an individual’s ability to care for their lower extremities, including the feet and nails. Age-related structural and functional changes further complicate foot health. As people age, their feet often become wider and longer, contributing to deformities, increased soft tissue stiffness, reduced range of motion, and diminished strength. Musculoskeletal conditions, such as arthritis, Charcot foot, hallux valgus or hallux varus, and plantar fasciitis, are also common in older adults. These issues heighten the risk of friction and shear, leading to the development of calluses, corns, wounds, falls, and even amputations.4 Collectively, these factors negatively affect balance, gait, joint mobility, and overall functional independence, significantly increasing the likelihood of falls and mobility limitations. Health habits play a critical role in lower extremity health, and addressing modifiable risk factors is essential for prevention. Cigarette smoking is one of the most significant contributors; it causes vasoconstriction, reduces blood flow, and increases the risk of peripheral arterial disease, ulcerations, and amputations.2 Patient education should strongly emphasize smoking cessation and reinforce the direct link between tobacco use and foot and nail health. Nutrition is equally important for maintaining tissue repair, immune defense, and skin integrity. Diets deficient in protein, vitamins A and C, zinc, or essential fatty acids increase susceptibility to fragile skin, delayed wound healing, and infection.5 Clinicians should encourage balanced dietary patterns, such as the Mediterranean diet, and highlight the importance of glycemic control for patients with diabetes. Excess body weight also places mechanical stress on the feet, contributing to deformities, callus formation, and joint pain. Obesity is closely associated with diabetes and metabolic syndrome, further increasing risks for neuropathy, vascular insufficiency, and poor wound healing. Education should therefore address weight management, safe physical activity, strengthening, stretching, and supportive footwear. QUESTIONS 1. A CFCN is educating a patient with diabetes mellitus about daily foot care, which of the following recommendations is MOST appropriate to reduce the risk of foot complications? A. Soak feet daily in hot water to improve circulation B. Inspect feet every day, including between the toes, using a mirror if necessary C. Apply moisturizer generously between toes to prevent dryness D. Wear tight-fitting shoes to improve stability Outline location: Domain 3 Task d 030104 knowledge Cognitive level: Recall ANSWER: B. Rationale: Daily inspection is critical for early detection of cuts, blisters, or infections. Patients should avoid hot water soaks, which are a burn risk, especially if they have neuropathy. Application of cream between toes may increase the risk of fungal infection. Shoes should not fit tight nor should socks. REFERENCES Beuscher T. Foot and nail care. In: McNichol L, Ratliff C, Yates S, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. 2nd ed. Wolters Kluwer; 2022:603-632. Song K, Chambers AR. Diabetic foot care. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. Updated July 24, 2023. Accessed September 1, 2025. https://www.ncbi.nlm.nih.gov/books/NBK553110/ 2. A CFCN is teaching caregivers about lifestyle factors that increase the risk of foot complications in patients with diabetes mellitus. Which of the following should be emphasized as a modifiable risk factor? A. Advancing age B. Smoking C. Peripheral neuropathy D. History of foot ulcer Outline location: Domain 3 Task 1g 030107 skill, knowledge 030103 Cognitive level: Application ANSWER: B. Rationale: While age, neuropathy, and prior ulcers are important risk factors for the foot care nurse to assess as factors impacting the plan of care, they are non-modifiable. Smoking is a major modifiable risk factor that worsens circulation and delays healing, so patient and caregiver education should strongly emphasize smoking cessation. REFERENCES Beuscher T. Foot and nail care. In: McNichol L, Ratliff C, Yates S, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. 2nd ed. Wolters Kluwer; 2022:603-632. McDermott K, Fang M, Boulton A, Selvin E, Hicks C. Etiology, epidemiology, and disparities in the burden of diabetic foot ulcers. Diabetes Care. 2023;46(1):209-221. doi:10.2337/dci22-004 3. The CFCN is instructing a patient with diabetes mellitus regarding preventive foot care measures. Which of the following statements by the patient would require further education? A. “I will moisturize my feet daily.” B. “I will inspect my feet daily for any injury or areas of pressure.” C. “I will go to the foot clinic to get my toenails trimmed.” D. “I keep the skin clean and dry between my toes.” Content outline: Domain 3, Task 1, 030104 Cognitive level: Analysis ANSWER: A. Rationale: Although the patient living with diabetes mellitus should moisturize their feet daily, they should be taught that moisturizer should not be placed between the toes as this can cause maceration, which can lead to a wound. Instead, the patient should be taught to daily inspect their feet for any pressure areas that can lead to wounds. This person should also be taught to monitor for any injury or current wounds, as these need to be addressed immediately. Many times, due to neuropathy, the patient does not know that they have a wound or area of pressure unless they visually inspect their feet. A good time for the patient to do this inspection is at night, when they are taking off their shoes and socks. Patients with diabetes mellitus should be taught that cutting their own nails can result in injury, which can result in a wound. Nails should be trimmed by an appropriate health care professional. Moisture between the toes, as stated earlier, can cause maceration, which can lead to a wound. The patient should be taught to dry the interdigits thoroughly after a bath or shower. REFERENCES Burdette-Taylor M, Fong L. Foot and nail care. In: Doughty DB, McNichol LL, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. 2nd ed Wolters Kluwer; 2022:530-554. Howes-Trammel S, Bryant RA. Foot and nail care. In: Acute and Chronic Wounds: Current Management Concepts. 5th ed. Elsevier; 2016:263-28. 4. The CFCN is performing a foot assessment in the clinic. Which of the following findings would warrant the most urgent attention? A. A callous to the lateral hallux B. An ABI reading of 1.20 mmHg C. Unilateral swelling and erythema D. Onychomycosis Content outline: Domain 3, Task 1, 030101 Cognitive level: Analysis ANSWER: C. Rationale: Callous formation is an indication of pressure and should be promptly addressed; however, it is not an urgent condition. Callous formation with a wound would require immediate attention. An ABI of 1.20 mmHg is slightly elevated and does require further investigation; however; it is not an urgent finding. Unilateral swelling and erythema can be indicative of a Charcot foot, which requires prompt attention by a podiatrist for casting to prevent further injury. Onychomycosis, which is a fungal nail infection, will need to be addressed as it can cause issues with the nail bed and skin; however, it is a long-term treatment process and is not an urgent condition with no wounds present. REFERENCES Burdette-Taylor M, Fong L. Foot and nail care. In: Doughty DB, McNichol LL, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. 2nd ed. Wolters Kluwer; 2022:530-554. Frazier WT, Santiago-Delgado ZM, Stupka KC 2nd. Onychomycosis: rapid evidence review. Am Fam Physician. 2021;104(4):359-367. PMID: 34652111. Dubský M, Bém R, Sojáková D, Fejfarová V, Hughes M, Jude EB. Charcot foot disease: a new approach. Drugs Aging. Published online August 11, 2025. doi:10.1007/s40266-025-01234-0. PMID: 40789985