A nurse is assessing a client's lower extremities and notes 6 mm pitting edema. Which of the following is appropriate documentation of this assessment finding?

Answer and Explanation

The Correct Answer is C

A. 1+ pitting edema is mild, with a slight indentation.

B. 4+ pitting edema is severe, with a deep indentation that lasts a long time.

C. 3+ pitting edema is moderate, with a deeper indentation that takes some time to rebound.
D. 2+ pitting edema is moderate, with a slight indentation that rebounds fairly quickly.

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Correct Answer is A

Explanation

A. If the nurse still has concerns after seeking clarification, the appropriate action is to contact another provider for a second opinion to ensure the safety and well-being of the client.
B. Withholding the treatment without further consultation may not be the best course of action.
Seeking additional input is important.
C. Carrying out the prescription despite concerns about its safety may pose risks to the client.
D. Notifying the ethics committee should be considered if there are ongoing ethical concerns or if the issue cannot be resolved through collaboration with other providers.

A. Provide the AP with a copy of the unit's policy. B. Notify the charge nurse about the incident. C. Talk with the AP about the technique used. D. Conduct an in-service on standard precautions.

Correct Answer is C

Explanation

A. Providing the AP with a copy of the unit's policy may be done but is not the first step. Direct communication is important for immediate feedback.
B. Notifying the charge nurse is appropriate but may not be the first action when direct communication with the AP can address the issue.
C. Talking with the AP about the technique used is the first and immediate action to address the observed lapse in infection control practices.
D. Conducting an in-service on standard precautions is a broader intervention and may be considered after addressing the immediate concern with the AP.

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A nurse is assessing a client's lower extremities and notes 6 mm pitting edema. Which of the following is appropriate documentation of this assessment finding?

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