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."

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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.

A. Anisocoria of the patient's pupils. B. Patient's accommodation response. C. Direct pupil response of the patient. D. Patient's consensual reflex.

Correct Answer is B

Explanation

A: Anisocoria refers to a condition where the pupils are of unequal sizes, which is not related to focusing ability.

B: Accommodation response involves the ability of the eye to change focus from distant to near objects, demonstrating the flexibility of the lens which is exactly what the instruction aims to test.
C: Direct pupil response relates to pupil constriction in response to light, not changes in focal distance.
D: Consensual reflex also refers to the reaction of both pupils to light and would not be assessed through changes in focal distance.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies subjective data as

Correct Answer is D

Explanation

The nurse gives the patient the following instructions: "Focus on the far wall and now focus on my pen." The nurse is assessing the

Correct Answer is B

Explanation

At the staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell) to determine whether a patient is exhibiting signs of illness or injury. These signs of illness or injury are

During the physical assessment, the nurse asks an elderly female patient if she experiences constipation. The nurse knows that

A nurse is collecting data on a client who reports acute pain at a level of 7 on a scale of 0 to 10. Which of the following findings should the nurse expect?

A nurse is assisting with teaching a newly licensed nurse about the loss of body heat. The nurse should include that heat loss that occurs when sweat dries on the skin is caused by which of the following mechanisms?

A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?

A nurse is assessing a sedated patient whose respiratory rate has fallen below 12 respirations per minute. The nurse identifies this condition as

A nurse is collecting data on client who has a heart rate of 56/min. Which of the following findings should the nurse expect?

When performing a thorough physical assessment on a patient, the licensed practical nurse (LPN) begins collecting primary data. An example of primary data is that