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. Hyperactive bowel sounds. Hyperactive bowel sounds are typically higher pitched and more frequent.

B. Possible renal artery stenosis. This is the best choice as a low-pitched blowing sound can indicate a bruit from renal artery stenosis.

C. Normal borborygmus sounds. Borborygmi are normal, loud, gurgling bowel sounds, not low-pitched blowing sounds.

D. A minor variation. A low-pitched blowing sound should not be considered a minor variation as it can indicate a serious condition.

A. Benign variation. B. Cardiac atrophy. C. Expected finding. D. Cardiac enlargement.

Correct Answer is D

Explanation

A. Benign variation. This finding is not typically considered a benign variation and warrants further evaluation.

B. Cardiac atrophy. Cardiac atrophy would likely present differently and is not typically diagnosed via percussion findings alone.

C. Expected finding. This finding is within normal limits for the size and location of the heart's borders on percussion.

D. Cardiac enlargement. Cardiac enlargement might present with percussion dullness extending beyond normal limits, but the described findings do not indicate enlargement beyond expected borders.

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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

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

Correct Answer is B

Explanation

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Correct Answer is D

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.