Safe, Effective Care Environment
8. A charge nurse on a medical-surgical floor observes a certified nursing assistant (CNA) taking care of a client with impaired vascular circulation. What behavior by the aide requires immediate action by the RN?
. Aide places client's feet in warm water.
. Aide elevates client's legs.
. Aide places sheepskin between overlapped toes.
. Aide applies lanolin to client's legs.
Test-Taking Tip
Eliminate the options that are familiar and effective strategies to improve venous return (Answer 2) and prevent skin breakdown (Answers 3 and 4).
Content Area: Adult Health, Vascular; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Supervision
Safe, Effective Care Environment
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Answer 1 is correct because heat is contraindicated since the client has reduced sensation from impaired vascular circulation. Injury may result. Answer 2 is incorrect because elevation will improve circulation and venous return. Answer 3 is incorrect because this action will prevent breakdown. Answer 4 is incorrect because this action is appropriate dry skin care in impaired vascular circulation.