A patient with a foot wound has a cool, pale foot, delayed capillary refill, and a weak pedal pulse. Which nursing action has the highest priority?
Correct answer: A. Report the impaired perfusion promptly
- A. Report the impaired perfusion promptly
- B. Apply a tight compression bandage to the foot
- C. Elevate the leg well above heart level
- D. Cover the wound with a warm heating pad
Explanation
The findings suggest impaired arterial circulation, which can rapidly threaten tissue viability and delay healing, so the nurse should report them promptly. Compression and marked elevation may further reduce arterial flow, while direct heat can burn tissue with poor sensation or perfusion.
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About Wound Care and Dressings
Wound care covers wound classification, healing stages, assessment of tissue and drainage, pain, infection signs, dressing selection and clean or sterile dressing technique. It also includes pressure injuries by stage and the factors affecting healing, such as nutrition, circulation, diabetes, infection and prolonged pressure.
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