The nurse enters the patient's room and the patient states, "I think my feet are swollen.". Which would be the nurse's next action?
The nurse applies pressure over a bony prominence of the foot for 2 seconds.
The nurse percusses the tissue that appears edematous
The nurse elevates the patient's feet on a pillow to decease swelling.
The nurse charts, "Patient's feet appear to be swollen."
The Correct Answer is A
A: Applying pressure over a bony prominence helps assess for pitting edema, a common indicator of fluid retention causing swelling. This action provides objective data to confirm the patient's subjective observation.
B: Percussion is not typically used to assess edema. It is more suitable for assessing the density of underlying structures.
C: Elevating the feet may help alleviate swelling but does not confirm the presence of edema.
D: Documenting the observation is important, but further assessment is needed to confirm the patient's concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Sonorous wheezes are low-pitched sounds and do not describe fine rales.
B: Musical or whistling sounds typically describe wheezes which are continuous and not the discontinuous sound of rales.
C: Noisy, snoring sounds are characteristic of rhonchi, not rales.
D: Fine rales are high-pitched, brief, and discontinuous crackling sounds that are often likened to the sound of hair being rubbed between fingers, indicative of fluid in the small airways.
Correct Answer is D
Explanation
A: Low blood pressure is an objective finding that can be measured directly.
B: Shortness of breath is a subjective symptom reported by the patient.
C: Wound drainage is an objective finding that can be observed directly.
D: Feelings of fatigue are subjective symptoms reported by the patient, reflecting their personal experience rather than directly observable physical signs.
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