A patient is admitted with an ulcer on the right great toe
The nurse determines that the blood pressure in the patient's right arm is 138 systolic, the left arm is 136 systolic, the right ankle is 65 systolic, and the left ankle is 66 systolic. How does the nurse evaluate these readings? 1. The wound will require debridement.
2. The patient is getting adequate circulation to the feet.
3. This ulcer is not likely to heal.
4. The patient needs intravenous fluids to support intravascular volume.
3
Rationale 1: The need for debridement is determined by the appearance of the wound, not by blood pressure measurements.
Rationale 2: The right ankle-brachial index (ABI) is 0.47 and the left ABI is 0.49. Neither reading supports an evaluation of adequate circulation.
Rationale 3: An ankle-brachial index (ABI) of less than 0.5 indicates poor prognosis for healing. The patient's right ABI is 0.47.
Rationale 4: The described assessment does not offer enough information to determine if IV fluids are needed.
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