The nurse is assessing a client on admission to the hospital. The client's leg appears as shown below:
What action by the nurse is best?
a.
Assess the client's ankle-brachial index.
b.
Elevate the client's leg above the heart.
c.
Obtain an ice pack to provide comfort.
d.
Prepare to teach about heparin sodium.
ANS: A
This client has dependent rubor, a classic finding in peripheral arterial disease. The nurse should measure the client's ankle-brachial index. Elevating the leg above the heart will further impede arterial blood flow. Ice will cause vasoconstriction, also impeding circulation and perhaps causing tissue injury. Heparin sodium is not the drug of choice for this condition.
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