The nurse is assessing a 64-year-old patient whose vital signs are normal, with a capillary refill time of 5 seconds. What should the nurse do next?

Ask the patient about a history of frostbite

Consider this a normal capillary refill time that requires no further assessment

Suspect that the patient has venous insufficiency

Consider this a delayed capillary refill time, and investigate further

Answer and Explanation

The Correct Answer is D

A. Ask the patient about a history of frostbite:
Frostbite is one possible cause, but not the first priority. Investigation should begin more broadly.

B. Consider this a normal capillary refill time that requires no further assessment:
Incorrect. Normal capillary refill is < 2 seconds. 5 seconds is delayed.

C. Suspect that the patient has venous insufficiency:
Capillary refill tests arterial perfusion, not venous status.

D. Consider this a delayed capillary refill time, and investigate further:
A refill >2 seconds may indicate peripheral arterial disease, hypothermia, or shock, and warrants further assessment.

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Correct Answer is B

Explanation

A. "You will require an urgent mammogram":
Not warranted unless there is a sudden or recent asymmetry, mass, or skin change.

B. "This is quite common to have slight asymmetry in size":
Breast asymmetry is normal and common unless accompanied by new findings or rapid change.

C. "This signifies a growth in the left breast":
This is an assumption-size difference alone does not indicate pathology.

D. "I will inform the physician right away":
Not necessary unless there are abnormal associated signs (e.g., dimpling, mass, discharge).

A. indicates that air is present in the subcutaneous tissues." B. reflects the blood flow through the pulmonary arteries." C. is caused by moisture in the alveoli." D. is caused by sounds generated from the larynx."

Correct Answer is D

Explanation

A. "...indicates that air is present in the subcutaneous tissues.":
Describes subcutaneous emphysema, not fremitus.

B. "...reflects the blood flow through the pulmonary arteries.":
Fremitus is not related to circulation.

C. "...is caused by moisture in the alveoli.":
Moisture in alveoli causes crackles, not tactile fremitus.

D. "...is caused by sounds generated from the larynx.":
Fremitus is the palpable vibration produced by vocalization, transmitted through bronchopulmonary tissues to the chest wall.

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The nurse is assessing a 64-year-old patient whose vital signs are normal, with a capillary refill time of 5 seconds. What should the nurse do next?

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Naxlex Comprehensive Predictor Exams

When performing a female breast examination, the nurse notes the left breast to be larger than the right. What should the nurse tell the patient?

Correct Answer is B

Explanation

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile fremitus…

Correct Answer is D

Explanation

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