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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale

The bell of the stethoscope is designed to auscultate low-frequency sounds, such as certain heart murmurs or bowel sounds, due to its larger surface area and lower diaphragm tension. Breath sounds, however, are generally higher frequency and require the diaphragm for optimal clarity and discrimination of adventitious sounds, which are often subtle and require careful attention to pitch and quality.

Choice B rationale

Limiting auscultation to only the posterior chest misses significant lung fields, especially the anterior and lateral segments of the upper and middle lobes. Comprehensive respiratory assessment necessitates evaluating all accessible lung surfaces to detect localized abnormalities, ensuring no consolidation, atelectasis, or pleural effusions are overlooked, providing a complete diagnostic picture.

Choice C rationale

Instructing the patient to breathe in and hold their breath would prevent the continuous airflow necessary to generate breath sounds. Auscultation relies on the movement of air through the tracheobronchial tree. Holding the breath eliminates this vital acoustic phenomenon, rendering the assessment ineffective for evaluating air entry, presence of adventitious sounds, or symmetry.

Choice D rationale

Comparing sounds on the left and right sides allows for the identification of unilateral abnormalities, which are crucial for diagnosing localized pathologies. This systematic approach helps detect differences in breath intensity, the presence of unilateral adventitious sounds like wheezes or crackles, or diminished air entry, guiding further diagnostic investigation and treatment.

Correct Answer is ["250"]

Explanation

Step 1: Refer to LABEL #2- CEFTRIAXONE. The label indicates that for IM administration, 0.5 g (500 mg) can be reconstituted with 1.8 mL of diluent to yield a concentration of 250 mg/mL.

Step 2: The question asks for the drug dosage after reconstitution for IM administration. The label explicitly states 250 mg/mL. Answer: 250 mg/mL.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What should the examiner do during auscultation of breath sounds?

Correct Answer is D

Explanation

What is the drug dosage after reconstitution for IM administration? (Use LABEL #2- CEFTRIAXONE)

Correct Answer is ["250"]

Explanation

The nurse is administering medications to the patient who is in renal failure resulting from end-stage renal disease. The nurse is aware that patients with kidney failure would most likely have problems with which pharmacokinetic phase?

The nurse is preparing to administer medications through a tube. Which of the following should she remember before administering the medications?

During a discussion about breast self-examination with a 30-year-old woman, which of these statements by the nurse is most appropriate?

A physician tells the nurse that a patient's skull is normocephalic. This finding during the physician's inspection reveals:

Before delivering a drug through an enteral tube, it is most important for the nurse to do which of the following FIRST?

A mother called the pediatrician's office, reporting that her infant son had a temperature of 102.6 F. The nurse is to record the information as a Celsius temperature. What should the nurse write down as the temperature reported by the mother?

Complete the following sentence using the list of options. When performing a physical assessment, the first technique the nurse will always use is?

Your client is complaining of "sudden, crushing chest pressure", and is having difficulty breathing. Her physician has ordered a STAT dose of nitroglycerin. When should you administer the medication?

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?