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 B
Explanation
Gentamicin is an antibiotic that is usually administered via IV infusion. The peak level is the highest concentration of the medication in the bloodstream, and it is important to monitor it to ensure therapeutic levels are achieved without reaching toxic levels.
Drawing the peak level 30 minutes after the infusion is complete allows enough time for the medication to distribute throughout the body and reach its peak concentration. This timing provides an accurate representation of the highest drug concentration in the bloodstream. 30 minutes before starting the infusion: Drawing the peak level before starting the infusion would not accurately reflect the peak concentration of the medication in the bloodstream. Immediately before the next dose of Gentamicin: Drawing the peak level immediately before the next dose would not provide an accurate assessment of the highest drug concentration, as the levels would have started to decrease due to elimination.
1 hour after infusion is complete: Waiting for 1 hour after the infusion is complete may result in missing the actual peak concentration of the medication in the bloodstream, as it may have already started to decline.
Correct Answer is C
Explanation
The pH value of 7.5 indicates alkalosis, as it is above the normal range of 7.35-7.45. The elevated bicarbonate (HCO3-) level of 34 mmol/L suggests metabolic alkalosis, as it is higher than the normal range of 22-28 mmol/L. The PaCO2 level of 40 mm Hg falls within the normal range of 35-45 mm Hg.
In this case, the primary disturbance is metabolic alkalosis, which is likely caused by the persistent vomiting leading to excessive loss of gastric acid (hydrogen ions) and chloride ions from the stomach. This loss of acid and chloride results in an imbalance of electrolytes and an increase in bicarbonate levels, leading to metabolic alkalosis.
Since there is no significant deviation from the normal range in the PaCO2 level, the respiratory system has not effectively compensated for the metabolic alkalosis. Therefore, it is considered uncompensated.
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