The nurse enters the patient's room and the patient states, "I think my feet are swollen.". Which would be the nurse's next action?
The nurse applies pressure over a bony prominence of the foot for 2 seconds.
The nurse percusses the tissue that appears edematous
The nurse elevates the patient's feet on a pillow to decease swelling.
The nurse charts, "Patient's feet appear to be swollen."
The Correct Answer is A
A: Applying pressure over a bony prominence helps assess for pitting edema, a common indicator of fluid retention causing swelling. This action provides objective data to confirm the patient's subjective observation.
B: Percussion is not typically used to assess edema. It is more suitable for assessing the density of underlying structures.
C: Elevating the feet may help alleviate swelling but does not confirm the presence of edema.
D: Documenting the observation is important, but further assessment is needed to confirm the patient's concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: To accurately determine a pulse deficit, one nurse must listen to the apical pulse while another nurse palpates the radial pulse simultaneously to compare both pulse rates, necessitating a second person.
B: Counting the apical pulse is a part of the process but would follow after ensuring another nurse is available to check the radial pulse at the same time.
C: This action relates to checking a pulse rate generally but does not specify the need for simultaneous comparison with the apical pulse.
D: Calculation of the difference is the final step after both pulses have been counted simultaneously.
Correct Answer is D
Explanation
A: Bradycardia is typically not associated with acute pain; instead, pain usually triggers a sympathetic response, leading to tachycardia.
B: Hypoglycemia has no direct correlation with acute pain levels.
C: Pain tends to increase, not decrease, the respiratory rate due to stress and increased metabolic demand.
D: Acute pain can lead to elevated blood pressure as part of the body's stress response, which includes activation of the sympathetic nervous system.
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