A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: Pitting edema; 8-mm pit. Pit remained for 4 minutes after pressing. What grade of edema has this nurse documented?
2+ Pitting Edema
3+ Pitting Edema
1+ Non-Pitting Edema
4+ Pitting Edema
The Correct Answer is D
A. 2+ Pitting Edema: This refers to moderate pitting edema where the indentation is approximately 4 mm and disappears within 10-15 seconds.
B. 3+ Pitting Edema: This refers to moderately severe pitting edema where the indentation is approximately 6 mm and may last longer than 1 minute but does not remain for as long as 4 minutes.
C. 1+ Non-Pitting Edema: This grade refers to mild pitting edema with a 2 mm indentation that quickly disappears within a few seconds.
D. 4+ Pitting Edema: 4+ pitting edema is characterized by a very deep pit (approximately 8 mm) that may last 2-5 minutes or more. This matches the scenario where the pit is 8 mm deep and remains for 4 minutes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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