Question

At 1130, the nurse assumes care of an adult client withdiabetes mellituswho was admitted with an infected foot ulcer. After reviewing the client’s electronic health record, whichpriority nursing actionshould the nurse implement?

A.Obtain antibiotic peak and trough levels.
B.Initiate hourly urine output measurements.
C.Administer insulin per sliding scale. (QL)
D.Assess appearance of foot wound.

Answer 1

The priority nursing action for a diabetic patient with an infected foot ulcer is to assess the appearance of the foot wound. This assessment is vital to determine the necessary interventions and prevent severe complications.

Step-by-step explanation:

The student asked what the priority nursing action should be for a patient with diabetes mellitus who was admitted with an infected foot ulcer. Considering the clinical focus provided, the priority is to assess the risk of complications from the infected wound, which could lead to serious conditions such as necrotizing fasciitis or sepsis. Therefore, the most important initial action for the nurse would be to assess the appearance of the foot wound (Option D). This assessment guides immediate and appropriate interventions, including necessary surgical debridement, antibiotic therapy, or additional diagnostics.

Based on the clinical focus sections, it is clear that diabetic wounds can escalate quickly if not adequately managed, leading to severe complications such as systemic infections that require immediate medical response. The prompt evaluation of the wound's condition is crucial to prevent these outcomes.