Question

A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. Which of the following focused assessments should the nurse use to help differentiate between an arterial ulcer and a venous stasis ulcer?

a. Assessment of capillary refill.

b. Evaluation of peripheral pulses.

c. Inspection of wound color and drainage.

d. Measurement of ankle circumference.

Answer 1

To differentiate between an arterial ulcer and a venous stasis ulcer, the nurse can use evaluations of peripheral pulses, measurement of ankle circumference, and inspection of wound color and drainage.

Step-by-step explanation:

In order to differentiate between an arterial ulcer and a venous stasis ulcer, the nurse can use the following focused assessments:

1. Evaluation of peripheral pulses: Arterial ulcers are often associated with decreased or absent peripheral pulses, whereas venous stasis ulcers typically have normal pulses.
2. Measurement of ankle circumference: Arterial ulcers are more likely to result in decreased ankle circumference, while venous stasis ulcers may cause normal or increased ankle circumference due to edema.
3. Inspection of wound color and drainage: Arterial ulcers often have a pale or necrotic appearance, and the drainage may be minimal. Venous stasis ulcers usually have a reddish or brownish color, and the drainage may be moderate to heavy.