A nurse is caring for a client with a chronic lower leg wound caused by venous insufficiency. Which action by the nurse is most appropriate?
a. Apply ice to the surrounding tissue.
b. Elevate the leg and apply compression stockings.
c. Keep the leg in one position to avoid further injury.
d. Position the leg flat with heels elevated off the bed.
B
A wound caused or worsened by venous insufficiency needs to be elevated and treated with compression (i.e., TED hose). Applying ice to the surrounding tissues may damage them and create a bigger wound. Keeping the leg in one position could contribute to pressure ulcer devel-opment. Positioning the leg flat would not be beneficial since venous return is enhanced with elevation.
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The nurse is assessing a 25-year-old primigravida who is 20 weeks pregnant. Which vital signs finding should the nurse report immediately to the physician?
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