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should not massage the legs or notify the doctor of warm feet (a normal finding).PTS: 1 DIF: Cognitive Level: Application REF: 419 OBJ: 10 (theory) TOP: Endovenous Laser Treatment KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 11. The nurse is caring for a 75-year-old patient with a history of diabetes and peripheral vascular disease (PVD). The nurse observes an inflamed and excoriated area on the patient’s right shin. Which intervention should the nurse perform first? a. Document the findings.b. Review the patient’s diet.c. Notify the primary care provider.d. Cover with clear occlusive dressing.ANS: D The nurse should first cover the area with a clear, occlusive dressing to protect the area from scratching and infection. The nurse should then document the findings, notify the primary care provider, and review nutritional intake to confirm adequacy for wound healing.PTS: 1 DIF: Cognitive Level: Analysis REF: 420 OBJ: 2 (theory) TOP: PVD: Skin Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance
12. The nurse is caring for a patient with a compression dressing. Which action indicates appropriate wound care? Compression therapy options include compression stockings, elastic tubular support bandages, intermittent compression devices, a paste bandage such as Unna boot, or placement of two to four layers of compression dressings to the affected area. Venous return is accomplished as the patient moves his leg and achieves pressure on the calf muscles. Compression dressings can be placed over wound dressings. The dressings help to reduce ulcer pain, keep the wound moist, and assist debridement. The dressing is changed from every 2 to 3 days to every few weeks depending on the type of dressing applied. An alcohol-based cleanser would be drying and harsh. Compression dressings do not necessitate use of a face mask.PTS: 1 DIF: Cognitive Level: Comprehension REF: 420 OBJ: 8 (theory) TOP: Venous Insufficiency: Compression Dressings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies