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 B
Explanation
A: Convection involves the movement of air or liquid around the body, which then carries heat away but does not involve phase change like evaporation.
B: Evaporation is the process where liquid (sweat) turns into vapor, removing heat from the surface it evaporates from, which is the primary cooling mechanism in sweating.
C: Conduction involves direct transfer of heat through contact with cooler objects, not relevant to the drying of sweat.
D: Radiation refers to heat transfer through electromagnetic waves and does not require the presence of an intervening medium, unlike the evaporation of sweat.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. The site where the blood pressure was obtained is important to document because blood pressure measurements can differ significantly between different parts of the body (e.g., arm versus thigh). Documenting the site ensures that future measurements can be compared appropriately.
B. Interventions implemented in response to a client's blood pressure need documentation to track what actions were taken and whether these actions had the intended effect on the patient's health status. This helps in assessing the efficacy of interventions.
C. A client's position when the blood pressure was obtained affects the readings; measurements might differ when taken in positions such as lying, sitting, or
standing. Accurate documentation of position helps in ensuring that readings are interpreted correctly.
D. The frequency in which a blood pressure is taken provides context for understanding how the patient’s blood pressure is trending over time, which is critical for ongoing management and therapeutic decisions, especially in unstable or critical patients.
E. A client's response to interventions implemented should be documented to evaluate whether the treatment plan needs adjustments and to understand how the patient is coping with the treatment. This documentation is crucial for patient safety and care continuity.
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