A nurse is assessing a client's lower extremities and notes 6 mm pitting edema. Which of the following is appropriate documentation of this assessment finding?

Answer and Explanation

The Correct Answer is C

A. 1+ pitting edema is mild, with a slight indentation.

B. 4+ pitting edema is severe, with a deep indentation that lasts a long time.

C. 3+ pitting edema is moderate, with a deeper indentation that takes some time to rebound.
D. 2+ pitting edema is moderate, with a slight indentation that rebounds fairly quickly.

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Correct Answer is A

Explanation

A. Keeping the client's bed linens dry helps maintain the client's comfort and prevents chilling associated with damp linens.
B. Applying an alcohol-water solution may increase evaporative cooling and is not a standard intervention for fever.

C. Encouraging increased fluid intake is appropriate to promote hydration, but the specific amount should be individualized based on the client's condition and needs.
D. Applying ice packs to the groin is not a recommended site for cooling and may cause discomfort. The choice of cooling measures should be appropriate and based on the healthcare provider's orders or institutional protocols.

A. Frequency of previous vital sign measurement B. Effectiveness of the last dose of pain medication C. Number of family members who have visited D. Time of the client's last bath

Correct Answer is B

Explanation

A. The frequency of previous vital sign measurements may be important but is not the most critical information to communicate during a transfer.
B. The effectiveness of the last dose of pain medication is crucial information for the receiving facility to manage the client's pain appropriately.
C. The number of family members who have visited is important for emotional support but may not be the priority for the receiving facility.
D. The time of the client's last bath is relevant but may not be as critical as information related to pain management during the hand-off report.

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A nurse is assessing a client's lower extremities and notes 6 mm pitting edema. Which of the following is appropriate documentation of this assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a temperature of 38.7° C (101.7° F). Which of the following nursing interventions is appropriate?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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