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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Tachypnea refers to rapid breathing, typically defined as a respiratory rate exceeding 20 breaths per minute.
B: Bradypnea is characterized by abnormally slow breathing, with a respiratory rate below the normal range.
C: Eupnea describes normal breathing, with a respiratory rate within the typical range for the patient's age and health status.
D: Apnea is the absence of breathing, not merely a decreased rate, and is considered a medical emergency.
Correct Answer is B
Explanation
A: Convection involves the movement of air or liquid around the body, which then carries heat away but does not involve phase change like evaporation.
B: Evaporation is the process where liquid (sweat) turns into vapor, removing heat from the surface it evaporates from, which is the primary cooling mechanism in sweating.
C: Conduction involves direct transfer of heat through contact with cooler objects, not relevant to the drying of sweat.
D: Radiation refers to heat transfer through electromagnetic waves and does not require the presence of an intervening medium, unlike the evaporation of sweat.
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