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","C","E"]

Explanation

A. Check the client's toes for color, temperature, and sensation: Assesses neurovascular status to detect signs of impaired circulation or nerve injury.

B. Apply heat to the client's ankle: Heat can increase swelling; ice should be used instead (RICE method: Rest, Ice, Compression, Elevation).

C. Apply a compression bandage to the client's ankle: Helps reduce swelling and provides support.

D. Encourage range of motion of the client's foot: Movement may worsen injury if a fracture or soft tissue damage is present.

E. Elevate the client's foot: Reduces swelling by promoting venous return.

A. Assess fluid balance. B. Introduce a regular diet. C. Rehydrate. D. Maintain fluid therapy.

Correct Answer is C

Explanation

A. Assess fluid balance. While assessment is important, treatment of dehydration (rehydration) is the priority in severe diarrhea.

B. Introduce a regular diet. Introducing a regular diet should come after rehydration, as severe diarrhea can lead to fluid and electrolyte imbalance that must be corrected first.

C. Rehydrate. The immediate priority is fluid replacement (oral or IV) to prevent hypovolemia, electrolyte imbalances, and shock.

D. Maintain fluid therapy. Maintaining fluid therapy is important after rehydration has begun, but initial rehydration is the priority intervention.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse is planning care for a child who has severe diarrhea. Which of the following actions is the nurse's priority?

Correct Answer is C

Explanation

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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?

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