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1. A client complains of calf tenderness, and throm- Increased cal
circumfer-
bophlebitis is suspected. The nurse would next assess ence
the client for which finding?
A. Bilateral edema
B. Increased calf circumference
C.Diminished distal peripheral pulses
D.Coolness and pallor of the affected
limb
2. The nurse is assessing a client's legs for the 1+ Edema
pres- ence of edema. The nurse notes that
the client has mild pitting with slight
indentation and no perceptible swelling of
the leg. How would the nurse define and
document this finding?
A. 1+ edema
B. 2+ Edema
C. 3+ Edema
D. 4+ Edema
3. A client is at risk for vasovagal attacks that cause brady- Applying
pressure on the
dysrhythmias. The nurse would tell the client to avoid eyes
which actions to prevent this occurrence? Select all that Raising the
arms above the
apply. E. Simulating a
gag reflex
A. Applying pressure on the eyes when
B. Raising the arms above the head brushing the
teeth
C. Taking stool softeners on a daily basis
D. Bearing down during a bowel movement
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, BSN 246 Week 2 HESI Prep with all Correct & 100%
Verified Answers |Actual Complete Exam| Already Graded
head reflex when brushing
Bearing down during a bowel movement Simulating a gag the teeth
4. The nurse assesses the sternotomy incision of a client Incision is
slightly edema-
on the third day after cardiac surgery. The tous but shows no
incision shows some slight puffiness along active signs of
the edges and is infection.
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