Health Promotion and Maintenance NCLEX PN Questions - Nurselytic

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Health Promotion and Maintenance NCLEX PN Questions Questions

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Question 1 of 5

When assessing a client with deep pitting edema, with the indentation remaining for a short time and visible leg swelling, how should a nurse document this finding?

Correct Answer: C

Rationale: The correct answer is 3+ edema. When assessing for edema, the nurse presses thumbs against the ankle malleolus or the tibia. If the skin retains an indentation, it indicates pitting edema. The grading scale for pitting edema includes: 1+ for mild pitting with slight indentation and no perceptible leg swelling, 2+ for moderate pitting where the indentation subsides rapidly, 3+ for deep pitting with an indentation remaining briefly and visible leg swelling, and 4+ for very deep pitting with a long-lasting indentation and significant leg swelling.

Choices A, B, and D do not accurately represent the severity of the edema described in the scenario.

Question 2 of 5

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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