The nurse is assessing an adult.
The adult's vital signs are normal, and capillary refill time is 5 seconds.
What should the nurse do next?
Ask the patient about a history of frostbite.
Suspect that the patient has venous insufficiency.
Consider this a delayed capillary refill time, and investigate further.
Consider this a normal capillary refill time that requires no further assessment.
The Correct Answer is C
Choice A rationale
Frostbite causes localized tissue damage due to ice crystal formation and cellular dehydration, leading to impaired circulation. While frostbite can affect capillary refill, a 5-second refill time in the absence of cold exposure or other correlating symptoms makes frostbite a less likely primary consideration and requires broader assessment.
Choice B rationale
Venous insufficiency involves impaired blood return to the heart, leading to venous stasis and edema. Capillary refill primarily assesses arterial perfusion and microcirculatory integrity, not venous outflow. Therefore, venous insufficiency would not typically manifest as a prolonged capillary refill time as a primary symptom.
Choice C rationale
Normal capillary refill time in adults is typically less than 2 seconds. A 5-second capillary refill time indicates impaired peripheral perfusion, suggesting inadequate blood flow to the capillaries. This delay warrants further investigation to identify underlying causes such as dehydration, hypovolemia, or peripheral vascular compromise.
Choice D rationale
Normal capillary refill time is typically less than 2 seconds. A 5-second refill time is significantly prolonged and indicates compromised peripheral circulation. Considering this normal would lead to a missed opportunity to identify and address a potentially serious underlying physiological issue affecting tissue perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
Step 1: The order is 10,000 units.
Step 2: The available concentration is 20,000 units per 1 mL.
Step 3: Calculate the volume to administer: 10,000 units ÷ (20,000 units ÷ 1 mL) = 0.5 mL. Answer: 0.5 mL.
Correct Answer is ["39.2"]
Explanation
Step 1 is: Subtract 32 from the Fahrenheit temperature. 102.6 - 32 = 70.6.
Step 2 is: Divide the result by 1.8. 70.6 ÷ 1.8 = 39.222.
Step 3 is: Round to the nearest tenth. The final calculated answer is 39.2 °C.
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.