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
Explanation
The correct answer is choice b. Three-point.
Choice A rationale:
The four-point gait is used when a client can bear weight on both legs. It involves moving one crutch forward, followed by the opposite leg, then the other crutch, and finally the other leg. This gait provides maximum stability but is not suitable for non-weight-bearing conditions.
Choice B rationale:
The three-point gait is appropriate for clients who cannot bear weight on one leg. In this gait, both crutches and the affected leg move forward together, followed by the unaffected leg. This allows the client to keep weight off the injured leg while moving.
Choice C rationale:
The two-point gait is used when a client can bear partial weight on both legs. It involves moving one crutch and the opposite leg forward simultaneously, followed by the other crutch and leg. This gait is faster than the four-point gait but still provides some stability.
Choice D rationale:
The swing-through gait is used by clients who have good upper body strength and balance. It involves moving both crutches forward together and then swinging both legs forward past the crutches. This gait is not typically recommended for clients who need to keep weight off one leg.
Correct Answer is B
Explanation
The correct answer is: B. Latex.
Choice A reason: Allergy to eggs is primarily a concern when it comes to vaccinations, such as the influenza vaccine, which may contain egg protein. In the context of IV therapy, egg allergies are not typically associated with direct contraindications or precautions. However, it’s important to note that some medications or vaccines may contain egg proteins, which could be relevant in certain medical procedures, but not usually in standard IV therapy.
Choice B reason: Latex allergies are particularly relevant in a hospital setting where latex is commonly found in various medical supplies, including gloves, catheters, and IV tubing. A latex allergy can cause severe reactions, including anaphylaxis, which is a life-threatening condition. Therefore, it is crucial for healthcare providers to be aware of a patient’s latex allergy to avoid exposure during medical procedures, including IV therapy.
Choice C reason: Seafood allergies are generally related to the ingestion of seafood and do not typically pose a risk in the context of IV therapy. The concern about iodine in contrast media, which is sometimes mistakenly linked to seafood allergies, is not relevant to standard IV therapy solutions.
Choice D reason: Bee sting allergies are significant when a patient is exposed to bee venom, which can cause anaphylaxis. In the context of IV therapy, a bee sting allergy is not typically a concern unless the therapy involves venom immunotherapy or the patient has had a recent bee sting that might complicate their medical condition.
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