During a morning assessment, the nurse observes that the patient ...

[Starlight]

During a morning assessment, the nurse observes that the patient displays significant edema of both feet and ankles. Which statement best documents these findings?
 
  a. Pitting edema present in both feet and an-kles
  b. Edema in both feet and ankles approx-imately 4 mm deep
  c. 4 mm pitting edema quickly resolving
  d. Bilateral pitting edema in feet and ankles, 4 mm deep, resolving in 3 seconds

Question 2

The 79-year-old patient with bacterial pneumonia becomes increasingly restless, confused, and agitated. The patient's temperature is 100 F, and his pulse, blood pressure, and respirations are elevated since the last assessment 6 hours ago.
 
  What action should the nurse take first?
  a. Auscultate the patient's lungs.
  b. Assess the patient's oxygen saturation.
  c. Administer the mild sedative as ordered.
  d. Administer an ordered analgesic for dis-comfort.

[Perkypinki]

Answer to Question 1

D
Edema should be recorded as to location, depth of pitting, and time for resolution.

Answer to Question 2

B
Outward signs of hypoxia vary in patients, but dyspnea, restlessness, and confusion are the most common signs. While blood gas analysis is the most reliable indicator, bedside assessment pulse oximetry is quick, noninvasive, and gives a snapshot of oxygen saturation. The nurse should auscultate the patient's lungs after obtaining the oxygen saturation. Medications for sedation or discomfort do not address the patient's current condition.

[Starlight]

Thanks for the timely response, appreciate it

[Jossy]

Gracias!