Difficulty: Medium
Average Score: 82%
Simulated
The nurse is checking for edema in the lower extremities of a patient with Congestive heart failure. The nurse will do which of the following when checking for edema. (Select all that apply)
Correct answer
A,B
Rationale
When checking for edema in congestive heart failure, the nurse grades the edema on a scale of +1 to +4 based on the depth of pitting and presses the skin over the tibia to assess for pitting edema. Plantar flexing the feet is unrelated to edema assessment, and checking only one limb is insufficient as edema may occur bilaterally.