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 D

Explanation

A. Corneas are jaundiced. Jaundiced corneas indicate liver dysfunction, but it is not typically an immediate life-threatening condition.

B. Eyelids are matted and crusted. This suggests an eye infection but does not require immediate intervention unless there are signs of systemic infection or severe pain.

C. Face is flushed and diaphoretic. Flushing and sweating can indicate fever, anxiety, or other conditions, but it is not immediately life-threatening.

D. Oral mucosa is cyanotic. Cyanosis indicates hypoxia and requires immediate intervention as it suggests a lack of adequate oxygenation.

A. Palpate the area for masses. B. Ask about recent abdominal trauma. C. Document the normal finding. D. Observe the midline for scarring.

Correct Answer is C

Explanation

A. Palpate the area for masses. Palpating for masses is important but is not specifically indicated by the observation of a depressed umbilicus.

B. Ask about recent abdominal trauma. Asking about trauma can be important but is not directly related to the finding.

C. Document the normal finding. This is the best choice because a depressed umbilicus is a normal variation and does not typically indicate pathology.

D. Observe the midline for scarring. Observing for scarring can be part of the assessment but is not directly indicated by the finding of a depressed umbilicus.

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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

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Explanation

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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.