Question

A client presents with a pressure ulcer on the ankle. Which is the first intervention that the nurse implements?

A. Place the client in bed and instruct him or her to elevate the foot.
B. Prepare for and assist with obtaining a wound culture.
C. Assess the affected leg for pulses, skin color, and temperature.
D. Draw blood for albumin, prealbumin, and total protein.

Answer 1

When a client presents with a pressure ulcer on the ankle, the nurse should first assess the leg for pulses, skin color, and temperature (option C) to determine circulation and potential infection.

Step-by-step explanation:

The first intervention a nurse should implement when a client presents with a pressure ulcer on the ankle is to assess the affected leg for pulses, skin color, and temperature. This initial assessment is crucial in determining the extent of the tissue damage and the ulcer's impact on the leg's circulation. Identifying changes in pulses, skin color, and temperature can inform the nurse about potential issues like decreased blood flow or infection, which can guide further treatment and interventions.

Following thorough assessment, the nurse can then proceed with appropriate interventions based on the findings, which may include elevating the foot, obtaining wound cultures, or drawing blood for analyses such as albumin, prealbumin, and total protein levels to evaluate nutritional status and aid in wound healing.