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?
1+
4+
3+
2+
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Giving oral care to a client who cannot take oral fluids is a task that can be safely delegated to an assistive personnel.
B. Checking intravenous insertion sites for signs of infiltration requires nursing judgment and assessment skills and should be performed by a licensed nurse.
C. Assessing a client's ability to ambulate involves clinical judgment and should be performed by a licensed nurse.
D. Demonstrating how to use a glucometer to a client with diabetes requires nursing knowledge and education skills and should be performed by a licensed nurse.
Correct Answer is A
Explanation
A. Applying a moisture barrier helps protect the skin from irritation and breakdown due to prolonged exposure to moisture.
B. Cleansing the skin with antibacterial soap and hot water may be too harsh and can contribute to skin irritation; gentle cleaning with a mild cleanser is preferable.
C. Toileting the client every 4 hours may not be frequent enough to prevent skin breakdown; a more frequent toileting schedule should be implemented.
D. Reducing the client's daily fluid intake is not a recommended intervention for urinary incontinence, as it may lead to dehydration and other health issues.
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