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How would the nurse document mild, slight pitting edema of the ankles, where there can be no perceptible swelling seen, the indentation depth will be less than 2mm, and the indentation will disappear in less than 10 seconds?

Answer and Explanation

The Correct Answer is B

A. 3+ edema indicates moderate pitting (indentation depth of 5-7 mm and lasting 10-20 seconds).

B. 1+ edema is classified as slight pitting (indentation depth less than 2 mm that disappears rapidly, typically in less than 10 seconds), making this the correct documentation.

C. 2+ edema indicates moderate pitting (indentation depth of 3-4 mm that lasts up to 15 seconds).

D. +0 indicates no edema present at all.

E. 4+ edema indicates severe pitting (indentation depth of greater than 8 mm and lasting more than 20 seconds).

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A. A client demonstrates how to inject insulin into the abdomen B. A client attends a course on exercise techniques C. A client watches the nurse apply a dressing D. A client lists food choices that are considered part of a healthy diet E. A client nods when told how to take the blood pressure medication

Correct Answer is ["A","D"]

Explanation

A. Demonstrating an insulin injection shows hands-on learning and mastery of the skill.

B. Attending a course does not confirm comprehension or skill.

C. Watching a nurse apply a dressing does not guarantee learning; active participation is necessary.

D. Listing healthy food choices indicates understanding of dietary education.

E. Nodding does not confirm learning; it may only indicate acknowledgment.

A. cannula prongs are curved downward to follow natural curve of nasal passages B. pressure areas of tubing along the skin of the ears are padded C. oxygen flow rate meter is set to 10 L/min D. no smoking signs and no open flame signs are posted and clearly visible E. cannula tubing is adjusted under the neck for proper fit

Correct Answer is C

Explanation

A. Curved prongs fitting the nasal passages correctly is appropriate practice for comfort and effective delivery.

B. Padding pressure areas on the skin is a best practice to prevent skin breakdown and is indicative of proper care.

C. An oxygen flow rate of 10 L/min is excessively high for a nasal cannula, which typically accommodates 1-6 L/min; this indicates a need for further education on proper flow rates.

D. Posting clear no smoking and no open flame signs is essential for safety in oxygen therapy, reflecting good practice.

E. Proper adjustment of cannula tubing under the neck is necessary to ensure a secure fit without causing discomfort.

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How would the nurse document mild, slight pitting edema of the ankles, where there can be no perceptible swelling seen, the indentation depth will be less than 2mm, and the indentation will disappear in less than 10 seconds?

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Correct Answer is ["A","D"]

Explanation

Correct Answer is C

Explanation

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Take full exam for free How would the nurse document mild, slight pitting edema of the ankles, where there can be no perceptible swelling seen, the indentation depth will be less than 2mm, and the indentation will disappear in less than 10 seconds?

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Which of the following scenarios gives the most absolute confirmation client learning has taken place? Select all that apply.

Correct Answer is ["A","D"]

Explanation

When the nurse manager is evaluating the care of a client receiving oxygen through a nasal cannula, which finding indicates a need for more staff education about oxygen therapy?

Correct Answer is C

Explanation

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How would the nurse document mild, slight pitting edema of the ankles, where there can be no perceptible swelling seen, the indentation depth will be less than 2mm, and the indentation will disappear in less than 10 seconds?