The patient who is confined to bed in the supine position has gained 5 lbs. in the last 48 hours. In which area does the nurse assess skin turgor for accurate determination of dependent edema?
Foot
Forehead
Ankle
Chest
Sacrum
The Correct Answer is E
Dependent edema refers to the accumulation of fluid in the dependent parts of the body, which are areas that are most affected by gravity when a person is in a supine or sitting position for an extended period. The sacrum, which is the triangular bone at the base of the spine, is one such dependent area. It is prone to developing edema when there is increased fluid retention in the body, as seen in the patient's weight gain.
To assess for dependent edema accurately, the nurse can gently press the skin over the sacral area with their fingers and observe the skin turgor or the return of the skin to its normal position after releasing the pressure. If there is edema, the skin may have reduced elasticity and take longer to return to its normal position (poor skin turgor).
While edema can occur in other dependent areas such as the feet, ankles, and lower legs, assessing skin turgor in these areas may not provide an accurate determination of dependent edema as they are located further away from the sacrum and may be influenced by other factors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Crackles and wheezing indicate the presence of excessive mucus or secretions in the airways, which may require suctioning to clear the airway and improve breathing.
The presence of serosanguineous drainage on the tracheostomy dressing may indicate increased mucus production or bleeding, suggesting the need for suctioning to remove secretions or assess for any bleeding complications.
Regular suctioning is necessary to maintain a patent airway for patients with a tracheostomy. If suctioning was performed more than 4 hours ago, it may be time for another suctioning session to prevent the accumulation of secretions and maintain airway clearance. While a fever may indicate an underlying infection or inflammation, it does not specifically indicate the need for suctioning. The decision to suction should be based on the patient's respiratory assessment and the presence of respiratory symptoms.
While patient requests and preferences are important, the need for suctioning should be determined based on clinical indicators and assessment findings rather than solely relying on patient requests.
Correct Answer is A
Explanation
Aminophylline is a bronchodilator that belongs to the xanthine derivative class of medications. It works by relaxing the smooth muscles surrounding the bronchial airways, which leads to bronchodilation. By dilating the airways, aminophylline helps to relieve bronchospasm, improve airflow, and facilitate easier breathing.
Prevent Infection: Aminophylline is not an antimicrobial medication, and its primary action is not related to preventing or treating infections.
Suppress the cough: While aminophylline may have some antitussive (cough-suppressing) effects, its primary action is bronchodilation rather than directly suppressing the cough reflex. Promote Expectoration: Aminophylline is not primarily indicated for promoting expectoration (bringing up mucus). It mainly focuses on bronchodilation to improve airflow and relieve bronchospasm.
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