A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document?
1+ pitting edema.
2+ pitting edema.
3+ pitting edema.
4+ pitting edema.
The Correct Answer is C
The correct answer is Choice C: 3+ pitting edema.
Choice A rationale:
1+ pitting edema refers to mild pitting edema. It is characterized by a slight indentation that disappears rapidly. A measurement of 6 mm edema is beyond the scope of 1+ pitting edema.
Choice B rationale:
2+ pitting edema indicates moderate pitting edema. It is characterized by a deeper indentation that takes a few seconds to rebound. While 6 mm edema might be associated with 2+ pitting edema, it is not the most accurate description.
Choice C rationale:
3+ pitting edema signifies moderately severe pitting edema. It is characterized by a noticeable indentation that remains for a short duration. A measurement of 6 mm edema aligns with 3+ pitting edema, making it the correct choice.
Choice D rationale:
4+ pitting edema represents severe pitting edema. It is characterized by a deep indentation that persists for a significant amount of time. 6 mm edema is not typically associated with 4+ pitting edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. "Tighten your stomach muscles.” This is because when turning an immobile client in bed, it’s important to use proper body mechanics to prevent injury. Tightening the stomach muscles helps to stabilize the core, which supports the spine and can help prevent back strain.
Choice A rationale:
"Keep your feet close together” is wrong because having a wide base of support with the feet apart provides better balance and stability when turning a client in bed.
Choice C rationale:
"Straighten your knees” is wrong because you should keep your knees slightly bent to maintain balance and allow for a smooth transfer of weight as you turn the client.
Choice D rationale:
"Bend at your waist” is wrong because bending at the waist increases the risk of a back injury. It’s important to bend the knees and keep the back straight when leaning over to turn a client.
Correct Answer is D
Explanation
The correct answer is **d. Attach a humidifier to the base of the flow meter**.
Choice A rationale:
Keeping the side holes of the mask closed would restrict airflow and prevent the client from receiving the prescribed oxygen concentration. This action would be unsafe and should not be taken.
Choice B rationale:
Ensuring the reservoir bag is inflated on expiration is not necessary for a simple face mask. The reservoir bag is typically used with other oxygen delivery devices, such as a non-rebreather mask, to provide a higher concentration of oxygen. This action is not appropriate for the given scenario.
Choice C rationale:
Applying petroleum jelly to the client's nostrils is not a recommended action. Petroleum jelly can potentially cause irritation and dryness, which could lead to discomfort for the client. This action is not necessary for the safe administration of oxygen.
Choice D rationale:
Attaching a humidifier to the base of the flow meter is the appropriate action to ensure client safety. Humidifying the oxygen can help prevent drying of the client's airway and make the oxygen more comfortable to breathe. This is a recommended step when administering high-flow oxygen via a simple face mask.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today