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

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is choice C: Skin fold returns to its usual shape quickly when released. When assessing skin turgor, the nurse is checking for the elasticity and hydration of the skin. In a normal assessment, when the skin fold is lifted or pinched, it should return to its usual shape quickly when released. This indicates good skin turgor, which is an indication of proper hydration. If the skin fold is difficult to lift or pinch (choice A), this indicates poor skin turgor and possible dehydration. If an indentation of 2 mm remains after releasing the skin fold (choice B), this indicates poor skin turgor and possible dehydration. If the skin fold returns to its usual shape slowly when released (choice D), this may indicate a decrease in skin elasticity and possible dehydration.

A. Cleanse the catheter from the meatus outward using mild soap and warm water. B. Use the same cleansing cloth for cleaning of the perineal area and the catheter tubing. C. Use chlorhexidine gluconate (CHG) to cleanse the perineal area

Correct Answer is A

Explanation

The correct answer is choice A. When performing hygiene care for a client with an indwelling catheter, the nurse should plan to cleanse the catheter from the meatus outward using mild soap and warm water. This helps to prevent infection and ensure proper hygiene. Using the same cleansing cloth for cleaning the perineal area and catheter tubing (choice B) is not recommended as it can cause contamination and increase the risk of infection. The use of chlorhexidine gluconate (CHG) to cleanse the perineal area (choice C) is not necessary for routine catheter care and should only be used for specific indications such as preventing infection during surgery. Therefore, the nurse should always follow proper hygiene protocols and cleanse the catheter from the meatus outward using mild soap and warm water when caring for a client with an indwelling catheter.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is performing a head-to-toe assessment on a patient. The nurse uses their thumb and first finger to lift or pinch a fold of skin under the clavicle to check for skin turgor. Which of the following findings would be considered normal for this assessment?

Correct Answer is C

Explanation

The nurse is planning to care for a client with an indwelling catheter. Which of the following measures should the nurse implement when performing hygiene care in regards to the indwelling catheter?

Correct Answer is A

Explanation

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