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 C
Explanation
The correct answer is Choice C: "Do you consume pork products?"
Choice C rationale: Islamic dietary laws, also known as Halal, prohibit the consumption of pork and its by-products. By asking the client about their consumption of pork products, the nurse demonstrates cultural sensitivity and ensures that the client's dietary preferences and religious practices are respected while under the facility's care.
Choice A rationale: Asking the client if they receive Holy Communion is not appropriate, as this practice is associated with Christianity rather than Islam. This question does not effectively address the client's religious preferences or needs in relation to their Islamic faith.
Choice B rationale: Inquiring about adherence to a kosher diet is not relevant, as this dietary practice is specific to Judaism and does not pertain to the Islamic faith. The nurse should be aware of the distinctions between religious practices when providing culturally competent care.
Choice D rationale: There is no general prohibition against blood transfusions in Islam. Islamic teachings generally permit medical treatments, including blood transfusions, when deemed necessary for the well-being and preservation of life. Asking the client about opposition to blood transfusions would not be the most effective way to clarify their religious preferences in the context of Islam.
Correct Answer is A
Explanation
Choice A rationale:
The correct answer. A piston syringe is used for wound irrigation to deliver a controlled and directed flow of fluid to clean the wound. It helps remove debris and promote healing. This choice aligns with wound irrigation best practices.
Choice B rationale:
Barrier ointment is not typically used for wound irrigation. Its purpose is to protect intact skin from moisture, friction, and other irritants, rather than to clean wounds.
Choice C rationale:
Chilled irrigation solution is not commonly used for wound irrigation. Room temperature or warm sterile saline is usually recommended for wound cleansing as cold solutions can cause discomfort and vasoconstriction.
Choice D rationale:
Sterile cotton balls are not used for wound irrigation. They may leave fibers in the wound, potentially leading to infection. Wound irrigation is usually performed using sterile syringes, solutions, and appropriate irrigation devices.
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