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

Answer and Explanation

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.

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Correct Answer is D

Explanation

The development of nausea and increased upper abdominal bowel sounds after 24 hours of NG decompression in a patient with gastric outlet obstruction raises concerns for possible complications or changes in the patient's condition. Assessing the patient's vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, can provide important information about their circulatory status and overall stability.

While checking the patency of the NG tube is important, it is not the best immediate action in this situation. The nurse should first assess the patient's vital signs to ensure their stability before proceeding with further interventions.

Placing the patient in a recumbent position (lying down) or encouraging deep breathing and conscious relaxation may not address the underlying issue and could potentially exacerbate the symptoms. It is essential to assess the patient's vital signs and circulatory status to determine the appropriate course of action.

A. "Antihistamines block release of histamine from mast cells and basophils." B. "Antihistamines block H1 receptors to prevent actions of histamine at these sites." C. "H1 antagonists can bind to H1 receptors, H2 receptors, and muscarinic receptors." D. "First-generation antihistamines are more selective than second-generation antihistamines."

Correct Answer is B

Explanation

Antihistamines primarily work by blocking the H1 receptors, which are the receptors responsible for mediating the actions of histamine in the body. By blocking these receptors, antihistamines prevent or reduce the effects of histamine, such as itching, sneezing, runny nose, and watery eyes. This is the main mechanism by which antihistamines provide their therapeutic effects. "Antihistamines block release of histamine from mast cells and basophils." This statement is incorrect. Antihistamines do not block the release of histamine; instead, they block the histamine receptors to prevent the effects of histamine.

"H1 antagonists can bind to H1 receptors, H2 receptors, and muscarinic receptors." This statement is incorrect. H1 antagonists, or H1 receptor blockers, specifically bind to H1 receptors and do not have significant affinity for H2 receptors or muscarinic receptors. "First-generation antihistamines are more selective than second-generation antihistamines." This statement is incorrect. First-generation antihistamines are generally less selective and can have more sedating and anticholinergic effects compared to second-generation antihistamines, which are designed to be more selective for H1 receptors and have reduced sedative properties.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with a gastric outlet obstruction has been treated with NG decompression. After the first 24 hours, the patient develops nausea and increased upper abdominal bowel sounds. What is the best action by the nurse?

Correct Answer is D

Explanation

A nursing instructor is teaching a group of nursing students about antihistamines. Which statement by a student indicates an understanding of the mechanism of action of the antihistamines?

Correct Answer is B

Explanation

Which nursing documentation demonstrates the integration of patient-centered care?

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