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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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).
Correct Answer is D
Explanation
A. "Do you wear glasses?":
Useful for vision screening, but not a key aspect of functional assessment post-stroke.
B. "Do you have any thyroid problems?":
Related to medical history, not daily functional ability.
C. "How many times a day do you have a bowel movement?":
Important for general health, but not a key functional task affected by a stroke.
D. "Are you able to dress yourself?":
Functional assessments aim to evaluate independence in activities of daily living (ADLs), especially post-stroke.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.