what is the correct way to assess for pitting edema

ATI LPN

ATI PN Comprehensive Predictor 2020 Answers

1. What is the correct way to assess for pitting edema?

A. Press over the bony area for 5 seconds and release
B. Press over the skin for 10 seconds and check for discoloration
C. Press the area and check for the presence of rash
D. Press the skin and assess for rebound tenderness

Correct answer: A

Rationale: The correct way to assess for pitting edema is to press over a bony area, typically the tibia, for 5 seconds and then release. This allows for the identification of pitting edema, characterized by an indentation that persists for a few seconds. Choice B is incorrect as pitting edema assessment does not involve checking for discoloration. Choice C is incorrect as the presence of a rash is not indicative of pitting edema. Choice D is incorrect as rebound tenderness is a different assessment used for abdominal conditions, not for pitting edema.

2. A client is constipated and asks the nurse for advice. What should the nurse recommend?

A. Administer a laxative to relieve discomfort
B. Increase dietary fiber to promote bowel movements
C. Advise the client to rest until symptoms resolve
D. Encourage bed rest to allow bowel function to return

Correct answer: B

Rationale: The correct recommendation for constipation is to increase dietary fiber to promote bowel movements. Dietary fiber helps add bulk to the stool, making it easier to pass and promoting regular bowel movements. Administering a laxative (Choice A) is not the first-line recommendation and should be used cautiously due to potential side effects. Resting until symptoms resolve (Choice C) and encouraging bed rest (Choice D) are not effective interventions for relieving constipation.

3. How should a healthcare professional assess a patient with dehydration?

A. Monitor skin turgor and check urine output
B. Assess for jugular venous distention
C. Auscultate lung sounds and monitor for fever
D. Monitor for cyanosis and increased respiratory rate

Correct answer: A

Rationale: Correct Answer: When assessing a patient for dehydration, healthcare professionals should monitor skin turgor, as it indicates the degree of dehydration, and check urine output, as decreased urine output can be a sign of dehydration. Choices B, C, and D are incorrect because they do not directly assess for dehydration. Assessing for jugular venous distention (B) is more relevant for heart failure, auscultating lung sounds and monitoring for fever (C) are more relevant for respiratory infections, and monitoring for cyanosis and increased respiratory rate (D) are more indicative of respiratory distress rather than dehydration.

4. What are the signs of hypovolemic shock and what is the nurse's role in management?

A. Rapid pulse, low blood pressure; administer IV fluids
B. Cold extremities, rapid breathing; administer oxygen
C. Decreased urine output, sweating; administer diuretics
D. Weak pulse, clammy skin; administer vasopressors

Correct answer: A

Rationale: The correct signs of hypovolemic shock are a rapid pulse and low blood pressure. Administering IV fluids helps to restore circulating volume, which is essential in managing hypovolemic shock. Choice B is incorrect because cold extremities and rapid breathing are not typical signs of hypovolemic shock. Choice C is incorrect as administering diuretics would further decrease circulating volume, worsening the condition. Choice D is incorrect as administering vasopressors may further compromise perfusion in hypovolemic shock.

5. A nurse is preparing to administer a rectal suppository to a school-age child. Which of the following actions should the nurse plan to take?

A. Insert the suppository 1 cm into the rectum
B. Insert the suppository 2 cm into the rectum
C. Insert the suppository past the anal sphincters
D. Insert the suppository using two fingers

Correct answer: C

Rationale: The correct answer is C: 'Insert the suppository past the anal sphincters.' When administering a rectal suppository, it is essential to insert it past the anal sphincters to ensure proper placement and absorption. Choices A and B are incorrect because the suppository should be inserted further than just 1 or 2 cm into the rectum to reach the optimal absorption site. Choice D is incorrect as using two fingers is not necessary and may cause discomfort to the child.