The nurse assesses the patient's hand distal to the arterial line and notes cool, pale fingers with a capillary refill of 6 seconds. What could be the reason for these findings?

Normal capillary refill

Improper positioning of the hand

Excessive blood flow to the distal area

Inadequate blood flow distal to the arterial line.

Answer and Explanation

The Correct Answer is D

A. A capillary refill time of 6 seconds is delayed (normal is <2-3 seconds).
B. Improper positioning could contribute but does not explain the sustained poor perfusion signs.
C. Excessive blood flow would cause warmth and redness, not coolness and pallor.
D. Cool, pale fingers with prolonged capillary refill indicate inadequate blood flow distal to the arterial line, possibly due to arterial occlusion or thrombosis. Immediate assessment and intervention are necessary.

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Correct Answer is B

Explanation

A. If the pilot balloon is inflated, the cuff cannot be deflated.
B. The pilot balloon is connected to the cuff; when the pilot balloon is inflated, it indicates that the cuff inside the trachea or airway is also inflated, providing a seal.
C. Partial inflation cannot be determined solely by the pilot balloon’s inflation status.
D. The pilot balloon is directly related to the cuff and serves as an indicator of its inflation status.

A. The rule of nines is based on the anatomical divisions of the body into nine equal areas. B. The rule of nines is used to calculate the total body surface area of a burn patient. C. The rule of nines is used to estimate the percentage of body surface area affected by burns. D. The rule of nines is only applicable to adults and not children.

Correct Answer is C

Explanation

A. The body is not divided into nine equal areas; the name refers to approximate multiples of nine for each section.
B. The rule helps estimate the percentage of body surface area (BSA) burned, not calculate total BSA.
C. The rule of nines is a quick method to estimate the percentage of total body surface area affected by burns in adults. Each major section of the body is assigned a value that is a multiple of nine, aiding in fluid resuscitation and treatment planning.
D. It is primarily used for adults; modified charts, such as the Lund and Browder chart, are more accurate for children due to their different body proportions.

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The nurse assesses the patient's hand distal to the arterial line and notes cool, pale fingers with a capillary refill of 6 seconds. What could be the reason for these findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

If the pilot balloon of a trach or ETT tube is inflated, what can be inferred about the cuff?

Correct Answer is B

Explanation

Which of the following is true about the rule of nines in a burn patient?

Correct Answer is C

Explanation

Which of the following statements is true about smoke inhalation injuries?

Which of the following is a primary purpose of hemodynamic monitoring?

What method is used as final confirmation of the proper placement of an endotracheal tube?

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The nurse assesses the patient's hand distal to the arterial line and notes cool, pale fingers with a capillary refill of 6 seconds. What could be the reason for these findings?

Which factors determine the severity of a burn injury?

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