A client drove himself to the urgent care center for Legs that look like balloons and difficulty walking. The nurse assesses 4+ edema of both legs based upon which finding?

Very deep pitting indentation of legs lasts several minutes.

Deep pitting indentation of legs lasts a few minutes.

Mild pitting no perceptible swelling of the legs.

Moderate pitting: indentation of legs subsides rapidly.

Answer and Explanation

The Correct Answer is A

Choice A rationale: 4+ edema is characterized by very deep pitting indentation of the legs that lasts several minutes. This indicates severe fluid retention and significant swelling.

Choice B rationale: Deep pitting indentation lasting a few minutes is more indicative of 2+ or 3+ edema, not 4+.

Choice C rationale: Mild pitting with no perceptible swelling is more indicative of 1+ edema, not 4+.

Choice D rationale: Moderate pitting with rapid subsidence is indicative of 3+ edema, not 4+.

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Correct Answer is C

Explanation

Choice A rationale: One minute is not sufficient to determine the absence of bowel sounds, especially in all quadrants.

Choice B rationale: Ten minutes in each quadrant is excessive and not a standard practice.

Choice C rationale: The nurse should listen for at least 1 minute in each quadrant before concluding that bowel sounds are absent, as they may be very faint or irregular.

Choice D rationale: Five minutes in each quadrant is excessive and not a standard practice.

A. Capillary refill <5 seconds. B. Radial pulses 2+ with regular rate and rhythm bilaterally C. Feet pale and cool to touch D. Right ankle 1+ edema with no perceptible swelling of the leg

Correct Answer is B

Explanation

Choice A rationale: A normal capillary refill time is less than 3 seconds, which indicates adequate blood flow and oxygenation.

Choice B rationale: Radial pulses 2+ with regular rate and rhythm bilaterally are expected findings in a peripheral vascular assessment, indicating normal blood flow to the extremities.

Choice C rationale: Pale and cool feet may indicate decreased blood flow and are not expected findings.

Choice D rationale: Ankle edema may indicate venous insufficiency or other circulatory issues, and it is not an expected finding in a healthy peripheral vascular assessment.

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A client drove himself to the urgent care center for Legs that look like balloons and difficulty walking. The nurse assesses 4+ edema of both legs based upon which finding?

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Naxlex Comprehensive Predictor Exams

During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. How long should the nurse listen before reporting absent bowel sounds?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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