A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following numbers should the nurse document to indicate the intensity of the client's edema?

Answer and Explanation

The Correct Answer is B

A. 4+: 4+ pitting edema corresponds to an indentation of 8 mm or more, which is more severe than the 6 mm described in the question.

B. 3+: 3+ pitting edema is characterized by an indentation of 6 mm and indicates moderately severe fluid retention.

C. 2+: 2+ pitting edema corresponds to an indentation of 4 mm, which is less than the 6 mm described.

D. 1+: 1+ pitting edema corresponds to an indentation of 2 mm, which is mild and does not match the severity in the scenario.

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Correct Answer is C

Explanation

A. Assess fluid balance. While assessment is important, treatment of dehydration (rehydration) is the priority in severe diarrhea.

B. Introduce a regular diet. Introducing a regular diet should come after rehydration, as severe diarrhea can lead to fluid and electrolyte imbalance that must be corrected first.

C. Rehydrate. The immediate priority is fluid replacement (oral or IV) to prevent hypovolemia, electrolyte imbalances, and shock.

D. Maintain fluid therapy. Maintaining fluid therapy is important after rehydration has begun, but initial rehydration is the priority intervention.

A. Examine the back before the general inspection of the skin. B. Note dry, flaky skin as an expected finding. C. Use a penlight to examine the back in greater detail. D. Pinch up a fold of skin to check for turgor.

Correct Answer is D

Explanation

A. Examine the back before the general inspection of the skin: Skin assessment should follow a general inspection.

B. Note dry, flaky skin as an expected finding: While common in older adults, it may indicate dehydration or dermatologic conditions.

C. Use a penlight to examine the back in greater detail: Penlights are typically used for darker areas (e.g., mouth, wounds), not flaky skin.

D. Pinch up a fold of skin to check for turgor: Assesses hydration status, which is important since dehydration contributes to dry, flaky skin.

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A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following numbers should the nurse document to indicate the intensity of the client's edema?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a child who has severe diarrhea. Which of the following actions is the nurse's priority?

Correct Answer is C

Explanation

A nurse is collecting data from an older adult client who comes to the clinic with dry, flaky skin on her upper back. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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