A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document?
1+ pitting edema.
2+ pitting edema.
3+ pitting edema.
4+ pitting edema.
The Correct Answer is C
The correct answer is Choice C: 3+ pitting edema.
Choice A rationale:
1+ pitting edema refers to mild pitting edema. It is characterized by a slight indentation that disappears rapidly. A measurement of 6 mm edema is beyond the scope of 1+ pitting edema.
Choice B rationale:
2+ pitting edema indicates moderate pitting edema. It is characterized by a deeper indentation that takes a few seconds to rebound. While 6 mm edema might be associated with 2+ pitting edema, it is not the most accurate description.
Choice C rationale:
3+ pitting edema signifies moderately severe pitting edema. It is characterized by a noticeable indentation that remains for a short duration. A measurement of 6 mm edema aligns with 3+ pitting edema, making it the correct choice.
Choice D rationale:
4+ pitting edema represents severe pitting edema. It is characterized by a deep indentation that persists for a significant amount of time. 6 mm edema is not typically associated with 4+ pitting edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
The correct answer is choice b. Wash hands after removing gloves, c. Use antimicrobial hand gel after refilling a client’s water pitcher, and d. Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.
Choice A rationale:
Placing immunocompromised clients in the same room can increase the risk of cross-infection among them. It is better to isolate them or place them in rooms with clients who have similar infection risks.
Choice B rationale:
Washing hands after removing gloves is crucial to prevent the spread of pathogens that might have contaminated the gloves during patient care.
Choice C rationale:
Using antimicrobial hand gel after refilling a client’s water pitcher helps to maintain hand hygiene and prevent the transmission of infections.
Choice D rationale:
Cleaning the stethoscope with an antimicrobial wipe after obtaining vital signs is essential to prevent the transfer of pathogens between patients.
Correct Answer is A
Explanation
The correct answer is choice a. "It must be difficult facing this type of surgery.”
Choice A rationale: This statement acknowledges the client’s feelings and provides emotional support, which is crucial in reducing anxiety and promoting a sense of understanding and empathy.
Choice B rationale: While this statement aims to reassure the client, it may come off as dismissive of the client’s unique concerns and feelings, potentially making them feel invalidated.
Choice C rationale: Although this statement highlights the facility’s reputation, it does not directly address the client’s immediate emotional needs or concerns about the surgery.
Choice D rationale: Offering a sleeping pill addresses the symptom (inability to sleep) but does not address the underlying anxiety or emotional distress the client is experiencing. Emotional support is often more effective in such situations.
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