The nurse is checking for edema in the lower extremities of a patient with Congestive heart failure. The nurse will do which of the following when checking for edema. (Select all that apply)
Grade the edema on a scale of +1 to +4.
Press the skin over the tibia.
Have the patient plantar flex their feet.
Check one limb only.
Correct Answer : A,B
When checking for edema in the lower extremities of a patient with Congestive heart failure, the nurse will grade the edema on a scale of +1 to +4 and press the skin over the tibia. Plantar flexing the feet is not necessary for assessing edema in the lower extremities, and checking only one limb is not sufficient as edema may occur in both legs.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Hypoxia is a medical condition characterized by a lack of oxygen in the body's tissues, which can occur due to a variety of reasons, such as respiratory failure, cardiac arrest, or other serious medical conditions. Cyanosis occurs when the oxygen saturation level in the blood falls below 85%, which causes a bluish color to appear on the skin, especially on the lips and fingertips. Therefore, if a nurse observes cyanosis in a patient's lips, it is a significant sign of hypoxia, and the patient requires immediate medical attention.

Correct Answer is A
Explanation
When assessing the abdomen, the nurse would expect to auscultate bowel sounds, which are the sounds made by the movement of gas and fluid through the intestines. The normal bowel sounds are characterized as high-pitched, gurgling, and occurring at a rate of 5-30 sounds per minute.

Bruits are abnormal sounds indicating turbulent blood flow and are usually assessed in other areas of the body, such as the epigastric and renal arteries, as well as in the aorta.
Friction rubs are also abnormal sounds, but they are typically heard during auscultation of the heart and lungs.
Low-pitched sonorous sounds are not typical sounds that are expected to be heard during an abdominal assessment
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