A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following numbers should the nurse document to indicate the intensity of the client's edema?

Answer and Explanation

The Correct Answer is B

A. 4+: 4+ pitting edema corresponds to an indentation of 8 mm or more, which is more severe than the 6 mm described in the question.

B. 3+: 3+ pitting edema is characterized by an indentation of 6 mm and indicates moderately severe fluid retention.

C. 2+: 2+ pitting edema corresponds to an indentation of 4 mm, which is less than the 6 mm described.

D. 1+: 1+ pitting edema corresponds to an indentation of 2 mm, which is mild and does not match the severity in the scenario.

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Correct Answer is A

Explanation

A. A reddened area over the sacrum. This is an early sign of a pressure ulcer, a common complication of immobility in bed-bound clients.

B. Difficulty moving the upper extremities. While weakness may occur after a stroke, this is not a complication of immobility but rather a direct effect of neurological damage.

C. Stiffness in the lower extremities. Some stiffness may occur, but contractures or deep vein thrombosis (DVT) would be more concerning immobility-related complications.

D. Difficulty hearing some types of sounds. Hearing loss is not a complication of immobility.

A. “They'll make it easier for you to do leg exercises after your surgery." B. "They'll help keep you warm immediately after your surgery." C. "They'll improve your circulation to keep blood from pooling in your legs and to control edema." D. "They'll protect your legs and heels from skin breakdown."

Correct Answer is C

Explanation

A. "They'll make it easier for you to do leg exercises after your surgery.": Stockings do not assist with leg exercises.

B. "They'll help keep you warm immediately after your surgery.": Primary function is not warmth but circulation improvement.

C. "They'll improve your circulation to keep blood from pooling in your legs and to control edema.": Antiembolism stockings promote venous return, preventing deep vein thrombosis (DVT) and swelling.

D. "They'll protect your legs and heels from skin breakdown.": While they provide some protection, their main purpose is preventing venous stasis and clot formation.

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A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following numbers should the nurse document to indicate the intensity of the client's edema?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

Correct Answer is A

Explanation

A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is observing a newly licensed nurse perform focused data collection on a client who has developed a skin condition. Which of the following questions by the newly licensed nurse requires intervention by the nurse?

A nurse is applying a cold compress for pain and minor swelling for a client who has a sutured laceration on the forearm. Which of the following data-collection activities should the nurse use to determine whether the treatment is effective?

A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy, and has a foul or unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

A child is being evaluated for increased work of breathing. While inspecting the child's chest, the nurse notes pulling in or sucking in of the skin between the child's ribs. How might the nurse accurately document this finding?

A nurse is assisting with the implementation of a bowel training program for a client. For the program to be effective, the nurse should take the client to the bathroom at which of the following times?

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