The patient has been found to have edema of the lower extremities. The nurse is assessing whether or not it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 4+ pitting edema because the rebound time is:
30 seconds to 1 minute
10-15 seconds
20 seconds
2-5 minutes
The Correct Answer is D
A. 30 seconds to 1 minute. – This time frame is characteristic of 3+ pitting edema, not 4+.
B. 10-15 seconds. – This time frame is associated with 2+ pitting edema, which indicates a moderate level of fluid retention.
C. 20 seconds. – This time frame is associated with 3+ pitting edema.
D. 2-5 minutes. – 4+ pitting edema is the most severe form, where the indentation remains for 2-5 minutes, indicating significant fluid retention and possible cardiac or renal dysfunction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Urine output – Febrile states do not affect urine output directly.
B. Body temperature – "Febrile" refers to an elevated body temperature (fever), which typically occurs due to infection or inflammation.
C. Blood glucose – Febrile states can be associated with metabolic changes, but febrile itself does not refer to blood glucose.
D. Digestive enzymes – Digestive enzyme levels are not linked to febrile states.
Correct Answer is A
Explanation
A. Region – In the PQRST pain assessment method, R stands for Region (location of pain). It helps determine where the patient feels discomfort and whether it radiates.
B. Recent – "Recent" does not correspond to any category in the PQRST system.
C. Random – "Random" is not a part of the PQRST framework.
D. Result – The PQRST method does not include "Result"; instead, it focuses on the characteristics of pain.
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