A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: Pitting edema; 8-mm pit. Pit remained for 4 minutes after pressing. What grade of edema has this nurse documented?

2+ Pitting Edema

3+ Pitting Edema

1+ Non-Pitting Edema

4+ Pitting Edema

Answer and Explanation

The Correct Answer is D

A. 2+ Pitting Edema: This refers to moderate pitting edema where the indentation is approximately 4 mm and disappears within 10-15 seconds.

B. 3+ Pitting Edema: This refers to moderately severe pitting edema where the indentation is approximately 6 mm and may last longer than 1 minute but does not remain for as long as 4 minutes.

C. 1+ Non-Pitting Edema: This grade refers to mild pitting edema with a 2 mm indentation that quickly disappears within a few seconds.

D. 4+ Pitting Edema: 4+ pitting edema is characterized by a very deep pit (approximately 8 mm) that may last 2-5 minutes or more. This matches the scenario where the pit is 8 mm deep and remains for 4 minutes.

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Correct Answer is B

Explanation

The correct answer is choice B, High Fowler's position. The High Fowler's position is the optimal position for nasogastric tube insertion as it allows for easy visualization and access to the nasal cavity, pharynx, and esophagus. The client should be in a semi-sitting position with the head of the bed elevated to at least 45-60 degrees. This position allows for better visualization and easier passage of the nasogastric tube through the nasal passages and into the esophagus. The other positions listed do not provide the optimal positioning for nasogastric tube insertion.

A. Along either upper gum line, adjacent to an incisor. B. Deep in the posterior sublingual pocket. C. In the inferior buccal space on either side of the tongue. D. Superior to the tongue with the tip touching the hard palate.

Correct Answer is B

Explanation

A. Along either upper gum line, adjacent to an incisor:Placing the thermometer along the upper gum line near the incisors would not accurately reflect the body's core temperature. The posterior sublingual pocket provides a more reliable reading.

B. Deep in the posterior sublingual pocket:The sublingual pocket, located under the tongue toward the back, is the best place for measuring oral temperature. This area has a good blood supply from the carotid arteries, making it ideal for an accurate temperature reading.

C. In the inferior buccal space on either side of the tongue:The buccal space is not ideal for temperature measurement, as it does not have the same consistent blood supply and is more prone to error due to airflow from breathing.

D. Superior to the tongue with the tip touching the hard palate:Placing the thermometer on top of the tongue against the hard palate would result in an inaccurate reading because this location does not effectively reflect the body's core temperature.

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A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: Pitting edema; 8-mm pit. Pit remained for 4 minutes after pressing. What grade of edema has this nurse documented?

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Naxlex Comprehensive Predictor Exams

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion?

Correct Answer is B

Explanation

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?

Correct Answer is B

Explanation

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