A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply.)
Explanation & Rationale
A. Check the client's toes for color, temperature, and sensation: Rationale: This assesses neurovascular status to ensure circulation and nerve function are intact distal to the injury. B. Apply heat to the client's ankle: Rationale: Heat should be avoided in the acute phase of a soft tissue injury (first 24–48 hours) as it can worsen swelling. Use ice instead. C. Elevate the client's foot: Rationale: Elevation helps reduce swelling by promoting venous return. D. Encourage range of motion of the client's foot and ankle: Rationale: During the acute injury phase, immobilization is key to prevent further damage. ROM exercises are introduced later. E. Apply a compression bandage or ace wrap to the client's ankle: Rationale: Compression reduces swelling and provides support. It should be applied properly to avoid compromising circulation.