A nurse is providing AM care to patients. Which action will the nurse take?
a. Soaks feet of patient with peripheral vascular disease
b. Applies CHG solution to wash perineum of patient with a stroke
c. Cleanses eye from outer canthus to inner canthus of patient with diabetes
d. Uses long, firm stroke to wash legs of patient with blood-clotting disorder
ANS: B
CHG is safe to use on the perineum and external mucosa. If patient has diabetes or peripheral vascular disease with impaired circulation and/or sensation, do not soak feet. Maceration of skin may predispose to infection. Do not use long, firm strokes to wash the lower extremities of patients with history of deep vein thrombosis or blood-clotting disorders. Use short, light strokes instead. Eye should be cleansed from the inner to outer canthus on all patients.
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