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 C
Explanation
Choice A rationale
Facilitation is a verbal technique that encourages the patient to say more by using non-verbal cues, such as nodding, or minimal verbal cues like "Mm-hmm" or "Go on.”. While it promotes communication, the statement "Tell me more about that" is a direct prompt for detailed information, not a subtle encouragement.
Choice B rationale
A direct ask is a specific question that elicits a concise, often one-word or brief, answer, such as "Are you in pain?" or "When did the shortness of breath start?" The nurse's statement, however, invites elaboration and detailed description, going beyond a simple direct response.
Choice C rationale
An open-ended ask is a type of question that encourages a comprehensive and descriptive response from the patient, rather than a simple yes or no answer. By asking "Tell me more about that," the nurse invites the patient to elaborate on their experience of shortness of breath, providing a richer understanding of the symptom.
Choice D rationale
Reflection involves repeating a patient's words or phrases to encourage further expression of their feelings or thoughts. While the nurse acknowledges the patient's mention of "shortness of breath," the statement "Tell me more about that" is an invitation for elaboration, not a direct reflection of the patient's exact words to encourage emotional exploration.
Correct Answer is ["1.1"]
Explanation
Step 1 is: 4500 units ÷ (4000 units/mL) = 1.125 mL.
Step 2 is: Rounding to the tenths place, the final calculated answer is 1.1 mL.
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