The nurse is checking for capillary refill on a child in Bryant's traction. How long does it take for the toe nailbed to regain color if adequate perfusion is assessed?
3 seconds
4 seconds
6 seconds
5 seconds
The Correct Answer is A
A. Normal capillary refill time is generally less than 3 seconds, indicating adequate peripheral perfusion.
B. Four seconds is prolonged and may suggest compromised circulation.
C. Six seconds is significantly delayed and indicates poor perfusion requiring immediate attention.
D. Five seconds is also prolonged and suggests impaired circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Mild clumsiness, such as difficulty with fine motor tasks (e.g., buttoning a shirt or writing), is often an early sign of ALS, reflecting initial weakness and muscle dysfunction.
B. ALS typically does not affect mental statusin the early stages; cognitive functions remain intact in most patients.
C. Muscle wasting occurs as the disease progresses, but it is not usually the first sign.
D. A diminished gag reflex may develop later in the disease as bulbar involvement increases, but it is not an initial manifestation.
Correct Answer is C
Explanation
A. Limiting fluid intake is not recommended and can lead to dehydration; fluids are important for overall health.
B. Larger meals may be overwhelming and difficult to consume for patients with Parkinson’s due to swallowing difficulties and fatigue.
C. Offering six small, frequent meals helps improve calorie intake without causing fatigue or difficulty swallowing large portions.
D. While milk and cheese provide nutrients, increasing dairy alone does not address the overall need for balanced, manageable nutrition.
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