The client has a round ulcer on the metatarsal head of the foot and nurse instructs the client about changing the dressing twice daily. Which does the nurse include in client teaching?
1. Report pale and cool skin changes in the toes.
2. Cover the dressing with a tight elastic bandage.
3. Take pain medication after the dressing change.
4. Remove tape with one quick pull to decrease pain.
1
1. An ulcer on the metatarsal head is usually due to impaired perfusion to the lower extremities, common in clients with diabetes mellitus and peripheral vascular disease; the nurse instructs the client to assess peripheral circulation to the toes by watching for pale or cool skin. The nurse instructs the client to report the findings because they can indicate impaired perfusion to the client's extremity that already has a high risk for infection and tissue or limb loss.
2. The nurse cautions the client to avoid wrapping the leg tightly because it poten-tially compromises arterial blood flow.
3. The nurse recommends taking pain medication before the dressing change if it is a painful event.
4. The nurse instructs the client to pull the tape slowly and gently toward the center to remove it.
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