Exhibits

The nurse reviews the electronic health record.

Highlight the finding(s) that require the nurse's attention. Select all that apply.

Heart rate 88 beats/minute

Blood pressure 122/72 mm Hg

Temperature 100.5° F (38° C)

Reports of pain with ambulation

Respirations 20 breaths/minute

Left lower leg with erythema, warm, and swollen

Blood glucose 252 mg/dL (13.9 mm

Based on the client's history, physical, and laboratory findings, the priority need will be to treat the infection (cellulitis). In addition, the client will need interventions to manage complications, especially deep tissue injury and impaired circulation.

Rationale:

The infection (cellulitis) is the primary concern, as indicated by redness, warmth, swelling, and systemic symptoms like muscle aches. Immediate antibiotic therapy is crucial.

Deep tissue injury is a potential complication due to prolonged inflammation, swelling, and impaired circulation, which can lead to tissue damage.

Impaired circulation is a significant risk in a client with diabetes and peripheral vascular disease, as it can slow healing and increase the likelihood of further complications such as ulcers or necrosis.

A. Serum blood glucose 185 mg/dL (10.2 mmol/L) (Incorrect): Although lower than the previous reading, it is still elevated, which can impair healing and increase the risk of infection recurrence.
B. Temperature 98.8°F (37.1°C) (Therapeutic Response): A return to a normal temperature indicates resolution of systemic infection. Fever is a sign of active infection, so its absence suggests improvement.
C. White blood cell count 11.2 x 10³/μL (11.2 x 10⁹/L) (Incorrect): This is slightly elevated, which may indicate residual inflammation or infection. A further decrease would be expected for full resolution.
D. Capillary refill greater than 3 seconds bilateral lower extremities (Incorrect): Delayed capillary refill suggests impaired circulation, which is not an indicator of a fully therapeutic response.
E. Bilateral lower extremities skin warm, dry, and pink (Therapeutic Response): Improved skin condition suggests reduced inflammation, better circulation, and healing of the cellulitis-affected area.
F. Pain 2 on a 0 to 10 pain scale, bilateral lower legs described as neuropathic (Therapeutic Response): Pain related to cellulitis typically improves with treatment. If the remaining pain is neuropathic, it suggests resolution of the acute infection.