A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses, paresthesia, and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should()
A. place a heating pad around the affected calf.
B. elevate the affected leg as high as possible.
C. keep the affected leg level or slightly dependent.
D. shave the affected leg in anticipation of surgery.
参考答案:C
解析:
While the physician makes treatment decisions, the nurse should maintain the client on bedrest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg may cause accidental trauma from cuts or nicks.