Practice Quiz

CRNE Exam Prep

Category - Changes in Health

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Evelyn, a 72-year-old female, was admitted to the facility due to myocardial infarction. On routine assessment, the nurse caring for Evelyn notes bilateral pitting edema in the lower extremities. Indention is 4 millimeters. Which of the following is the most appropriate action of the nurse?
  1. Inform the clientthat she should limit her intake of sodium to 1 gram a day.
  2. Recommend diuretic administration at bedtime.
  3. Review the client’s fluid intake and output for the last 48 hours.
  4. Inform the clientthat she should limit her fluid intake to 1,500 mL per day.
Explanation
Answer: C - The most appropriate action of the nurse is to review the client’s fluid intake and output for the last 48 hours. The client’s edema is graded 2, which is not severe. Fluid intake and sodium restriction are initiated with severe edema. Diuretics are administered in the morning to avoid nocturia.
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