Patient Data
Exhibits

When assessing the client's capillary refill status, what would be considered during the procedure? Select all that apply.

Capillary refill is measured in seconds

Capillary refill is the time it takes to return to the client's normal color after releasing pressure

Use your thumbnail and press the nailbed proximal to the injury

Normal should be within 3 seconds or 5 in the older adult

Pressure placed on the nailbed should cause blanching (pale)

Answer and Explanation

Correct Answer : A,B,E

A. Capillary refill is measured in seconds. This is correct. Capillary refill time is a measure of how quickly blood returns to the capillaries after pressure is applied and then released. It is typically measured in seconds.

B. Capillary refill is the time it takes to return to the client's normal color after releasing pressure. This is correct. Capillary refill time measures how quickly the color returns to the nailbed after pressure is applied. This indicates the adequacy of blood flow to the extremity.

C. Use your thumbnail and press the nailbed proximal to the injury. While you should press on the nailbed to assess capillary refill, it is generally recommended to use the pad of your thumb or finger rather than the thumbnail. Additionally, it's important to avoid pressing near the injury site if the area is bruised or painful, as this could distort the assessment.

D. Normal should be within 3 seconds or 5 in the older adult. A normal capillary refill time is generally within 2 seconds for adults. However, it can be up to 3 seconds in some clinical settings. For older adults, the time may be slightly longer, but 5 seconds is usually considered abnormal and may indicate poor perfusion.

E. Pressure placed on the nailbed should cause blanching (pale). This is correct. The application of pressure to the nailbed should cause blanching or paling of the area. The refill time is measured by how quickly the color returns to the nailbed once the pressure is released.

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Correct Answer is B

Explanation

A. Recent over-the-counter infection cures. This is less immediately relevant unless directly related to lymph node changes.

B. Nontender, firm lymph nodes. This is the correct choice. Nontender, firm lymph nodes can indicate a more serious underlying condition such as malignancy or chronic infection and require further investigation.

C. Number of indoor cats at home. This might be relevant if there is a concern for cat scratch disease, but it is less critical than the nature of the lymph nodes.

D. Amount of daily caffeine consumption. This is not related to the palpation of lymph nodes and is not immediately relevant to the findings.

A. Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation. B. Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly. C. Place the palm of the hand on the chest wall to feel vibrations while the client speaks. D. Looking at the client from the side, observe the size and shape of the chest wall.

Correct Answer is C

Explanation

A. Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation. This action is more appropriate for assessing crepitus, which is different from tactile fremitus.

B. Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly. While important in the assessment of pneumonia, this action assesses breath sounds, not tactile fremitus.

C. Place the palm of the hand on the chest wall to feel vibrations while the client speaks. This is the correct method for assessing tactile fremitus. Vibrations felt through the chest wall indicate changes in lung density, often found in conditions like pneumonia.

D. Looking at the client from the side, observe the size and shape of the chest wall. This action assesses the overall structure and symmetry of the chest but does not assess tactile fremitus.

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Patient Data Exhibits When assessing the client's capillary refill status, what would be considered during the procedure? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is examining a female client who states, she has no complaints, so has not had a physical examination for over 5 years. The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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Patient Data
Exhibits

When assessing the client's capillary refill status, what would be considered during the procedure? Select all that apply.