How would the nurse document mild, slight pitting edema of the ankles, where there can be no perceptible swelling seen, the indentation depth will be less than 2mm, and the indentation will disappear in less than 10 seconds?

Answer and Explanation

The Correct Answer is B

A. 3+ edema indicates moderate pitting (indentation depth of 5-7 mm and lasting 10-20 seconds).
B. 1+ edema is classified as slight pitting (indentation depth less than 2 mm that disappears rapidly, typically in less than 10 seconds), making this the correct documentation.
C. 2+ edema indicates moderate pitting (indentation depth of 3-4 mm that lasts up to 15 seconds).
D. +0 indicates no edema present at all.
E. 4+ edema indicates severe pitting (indentation depth of greater than 8 mm and lasting more than 20 seconds).

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Correct Answer is D

Explanation

A. A pulse of 60 is low but does not necessarily indicate a need to stop suctioning if the patient remains stable otherwise.
B. A pulse of 90 is within normal limits and does not require stopping suctioning.
C. An oxygen saturation of 92% is slightly low but still acceptable; suctioning can continue if the client is stable.
D. An oxygen saturation of 89% is below the acceptable threshold and indicates hypoxia, prompting the nurse to stop suctioning immediately to avoid further compromising the client's respiratory status.
E. A blood pressure of 130/80 is within normal limits and does not warrant cessation of suctioning.

A. Auscultate for any cardiac murmurs B. Compare the apical and radial pulse rates C. Palpate the quality of the peripheral pulses D. Find the point of maximal impulse E. Check capillary refill time

Correct Answer is A

Explanation

A. Auscultate for any cardiac murmurs is correct, as a thrill often indicates turbulent blood flow, which may correlate with murmurs that can be heard upon auscultation.
B. Comparing apical and radial pulse rates is useful in assessing pulse deficits but does not directly address the cause of the thrill.
C. Palpating the quality of the peripheral pulses does not provide specific information about the thrill's origin.
D. Finding the point of maximal impulse is a useful cardiac assessment but does not directly explain the cause of the thrill.
E. Checking capillary refill time assesses peripheral perfusion but does not relate to the thrill's cause.

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How would the nurse document mild, slight pitting edema of the ankles, where there can be no perceptible swelling seen, the indentation depth will be less than 2mm, and the indentation will disappear in less than 10 seconds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to suction a client. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning?

Correct Answer is D

Explanation

When assessing a newly admitted client, the nurse notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which action will the nurse take next?

Correct Answer is A

Explanation

What subjective data should the nurse obtain about a client's cardiac status? Select all that apply.

When auscultating the lungs of an adult client, the nurse notes that low-pitched, soft breath sounds are heard over the lower lobes. How would the nurse interpret these findings?

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The nurse is observing the lung auscultation technique of a student nurse. What is the correct method to use when progressing from one auscultatory site to another?

The nurse is percussing over the lungs of a client with pneumonia. What sound will the nurse expect to hear?

How would the nurse document mild, slight pitting edema of the ankles, where there can be no perceptible swelling seen, the indentation depth will be less than 2mm, and the indentation will disappear in less than 10 seconds?

When assessing tactile fremitus, increased tactile fremitus is expected under which condition?

The nurse receives orders for an opiate pain medication for a client with severe pain. What other order does the nurse anticipate getting?