hard · NCLEX-RN safety
The home health nurse is managing negative-pressure wound therapy (NPWT) for a 67-year-old client with a chronic, non-healing venous stasis ulcer of the left lower extremity. The client's medication list includes: aspirin 81 mg daily, metoprolol succinate 50 mg daily, and lisinopril 10 mg daily. Which of the following observations during the weekly home visit require the nurse to pause the therapy and contact the wound care provider? Select all that apply.
- The client's blood pressure is measured at 112/68 mm Hg, which is 10 mm Hg lower than the client's baseline.
- The client reports mild, transient itching of the intact skin directly under the outer edge of the transparent adhesive drape.
- Presence of a small amount of dark, dried serosanguineous drainage on the edges of the foam inside the intact dressing seal.
- The nurse notes a strong, putrid, foul odor and green, purulent drainage pooling under the transparent drape with a temperature of 38.5°C (101.3°F).
- The client reports a new, deep-seated, disproportionate throbbing pain, and the left foot is cool to the touch with a capillary refill of 5 seconds.
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