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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?

A.

3+

B.

1+

C.

2+

D.

+0

E.

4+

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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Correct Answer is C

Explanation

A. Supine is not recommended, as it can make breathing more difficult by limiting chest expansion.

B. Trendelenberg is not suitable for someone with breathing difficulties, as this position can worsen dyspnea.

C. High-Fowler is the best position for an asthma patient experiencing shortness of breath as it promotes lung expansion and allows for maximum chest wall movement.

D. Semi-Fowler may help but is less effective than High-Fowler in cases of acute respiratory distress.

E. Left-lateral does not optimize chest expansion and is not typically recommended for respiratory distress.

Correct Answer is E

Explanation

A. Chest percussion is a specialized skill that should be performed by a nurse or respiratory therapist due to the risk of complications.

B. Lung auscultation requires assessment skills and clinical judgment, which is within the RN’s scope of practice, not the CNA’s.

C. Taking vital signs on a client with severe dyspnea may require immediate interpretation and intervention, best handled by an RN.

D. Suctioning requires skill and knowledge of the procedure and potential complications, which should be performed by the RN.

E. Setting up a meal tray is an appropriate task for a CNA, as it does not require nursing judgment and supports the client’s nutritional needs.

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