A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first?
a. Draw blood for albumin, prealbumin, and total protein.
b. Prepare for and assist with obtaining a wound culture.
c. Place the client in bed and instruct the client to elevate the foot.
d. Assess the right leg for pulses, skin color, and temperature.
ANS: D
A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with his or her fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot would impair the ability of arterial blood to flow to the area.
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