A nurse is assessing a client with a history of heart failure who presents with severe edema in the lower extremities. The nurse would document the presence of +4 pitting edema after noting which finding?

Severe pitting, very swollen leg and indentation that lasts for a long time, 8 mm deep

Slight indentation, with no perceptible swelling of the leg. 2 mm deep

Moderate pitting, with indentation that subsides rapidly, 4 mm deep

Deep pitting, swollen leg, and indentation that remains for a short time, 6 mm deep

Answer and Explanation

The Correct Answer is A

A. +4 pitting edema is characterized by severe pitting that creates a deep indentation (greater than 8 mm) that remains for a prolonged period. This description matches the findings in option A.

B. This describes +1 pitting edema, which is not consistent with +4 edema.

C. This option describes +2 or +3 pitting edema, as the indentation subsides rapidly, which does not align with +4.

D. Although this describes deep pitting, the depth is less than 8 mm, which is not consistent with +4 edema.

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Correct Answer is C

Explanation

A. Metabolic alkalosis is characterized by a high pH and a high HCO3- level; this does not match the provided values.

B. Metabolic acidosis would show a low pH and a low HCO3-, which does not match the findings.

C. The pH is high (7.45) while the Paco2 is low (30 mm Hg), indicating respiratory alkalosis. The low HCO3- could be a compensatory mechanism but does not change the primary interpretation of respiratory alkalosis.

D. Respiratory acidosis would be indicated by a low pH and a high Paco2, which is not the case here.

A. Pustule B. Macule C. Papule D. Patch

Correct Answer is D

Explanation

A. A pustule is a small elevation of the skin that contains pus, typically smaller than 0.5 cm.

B. A macule is a flat, discolored area of skin that is less than 0.5 cm in diameter, so it does not fit the description of elevated lesions larger than 0.5 cm.

C. A papule is an elevated, solid lesion that is less than 0.5 cm in diameter; lesions larger than this would not be classified as papules.

D. A patch is defined as a flat, non-palpable lesion larger than 0.5 cm, and psoriasis can present as patches. Thus, the lesions described fit this classification.

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A nurse is assessing a client with a history of heart failure who presents with severe edema in the lower extremities. The nurse would document the presence of +4 pitting edema after noting which finding?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Explanation

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