A nurse is assessing a client's peripheral perfusion by checking capillary refill. Which action should the nurse perform?

Rationale:

A. A capillary refill time of 3 to 5 seconds is longer than normal and may indicate poor peripheral perfusion, dehydration, shock, or circulatory compromise. This is considered abnormal and requires further assessment.

B. Less than 2 seconds is normal capillary refill time for healthy adults. It indicates that peripheral circulation is adequate, and blood is returning quickly to the capillaries after blanching. This measure is a simple, noninvasive way to assess tissue perfusion and cardiovascular function.

C. More than 5 seconds is abnormal and often signals impaired peripheral circulation. Causes can include hypovolemia, heart failure, or peripheral vascular disease. This finding warrants prompt evaluation and intervention.

D. A capillary refill time of 10 seconds is significantly prolonged and indicates severe compromise of peripheral perfusion. It is abnormal and may reflect shock, severe dehydration, or circulatory failure, requiring urgent assessment and intervention.

Rationale:

A. A 2 cm erythematous lesion is objective data because it can be observed, measured, and verified by the nurse. Objective data are factual and measurable rather than based on the patient’s personal experience.

B. Skin that is warm and dry to touch is also objective data. The nurse can palpate and assess these characteristics directly, making them measurable and independent of the patient’s perception.

C. Capillary refill of 2 seconds is an objective finding, as it is measurable and can be verified through observation. This data provides information about peripheral perfusion rather than the patient’s personal experience.

D. The client reporting itching on both arms is subjective data, because it reflects the patient’s personal perception and experience. Subjective data cannot be directly measured or observed, but it is essential for understanding symptoms, guiding care, and identifying potential skin conditions such as dryness, allergy, or dermatitis.