A nurse is assessing a client with a history of heart failure who presents with severe edema in the lower extremities. The nurse would document the presence of +4 pitting edema after noting which finding?
Severe pitting, very swollen leg and indentation that lasts for a long time, 8 mm deep
Slight indentation, with no perceptible swelling of the leg. 2 mm deep
Moderate pitting, with indentation that subsides rapidly, 4 mm deep
Deep pitting, swollen leg, and indentation that remains for a short time, 6 mm deep
The Correct Answer is A
A. +4 pitting edema is characterized by severe pitting that creates a deep indentation (greater than 8 mm) that remains for a prolonged period. This description matches the findings in option
B. This describes +1 pitting edema, which is not consistent with +4 edema.
C. This option describes +2 or +3 pitting edema, as the indentation subsides rapidly, which does not align with +4.
D. Although this describes deep pitting, the depth is less than 8 mm, which is not consistent with +4 edema.
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Correct Answer is B
Explanation
A. Asystole: Asystole would show a flat line with no electrical activity, which is not seen here.
B. Ventricular fibrillation: Ventricular fibrillation is characterized by chaotic, irregular waveforms without distinct P waves, QRS complexes, or T waves. The ECG strip shows this disorganized, erratic electrical activity consistent with ventricular fibrillation.
C. Sinus tachycardia: Sinus tachycardia would display a regular rhythm with identifiable P waves, QRS complexes, and T waves at a faster rate. This is not present in the ECG strip.
D. Sinus bradycardia: Sinus bradycardia would show a slower rate but with an organized rhythm and distinct P, QRS, and T waves. This is not indicated in the strip.
Correct Answer is D
Explanation
A. The tympanic temperature of 37.1° C (98.8° F) is within normal limits and does not require re-measurement.
B. The respiratory rate of 14/min is also within the normal range (12-20 breaths per minute).
C. The blood pressure of 98/77 mm Hg is not alarmingly low and does not require immediate re-measurement.
D. A pulse rate of 42/min indicates bradycardia (normal resting heart rate is typically between