Free flow or withdrawal of fluids from a wound or a cavity is termed:

A. Symptoms – Symptoms are subjective findings reported by the patient, such as headache or nausea, which cannot be measured directly by the nurse.

B. Signs – Signs are objective findings that can be observed or measured, such as a fever or rash.

C. Assessments – An assessment is the process of gathering data but is not a specific term for patient-reported issues.

D. Observations – Observations refer to what the nurse sees or detects rather than what the patient reports.

A. Peripheral pulses that can be assessed include brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial. – These are key arterial pulse points used to assess circulation and vascular health.

B. Assess the radial pulse rate by counting the pulsations for 60 seconds. – Counting for a full minute provides the most accurate heart rate measurement, especially if irregularities are present.

C. On a person with good cardiac function and distal perfusion, capillary refill should take less than 6 seconds. – Normal capillary refill time (CRT) is ≤2 seconds. A refill time >2 seconds suggests poor perfusion.

D. The strength of the pulse can be measured using the following scale: 0, 1+, 2+, and 3+. –. The standard pulse grading scale ranges from 0 to 4+.