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The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?

Consider this a normal capillary refill time that requires no further assessment.

Consider this a delayed capillary refill time, and investigate further.

Ask the patient about a history of frostbite.

Suspect that the patient has venous insufficiency.

Answer and Explanation

The Correct Answer is B

A. Capillary refill time greater than 2 seconds is abnormal and requires further assessment.

B. A capillary refill time of 5 seconds indicates delayed peripheral perfusion and warrants further investigation.

C. While frostbite can cause delayed refill, it is less likely than vascular insufficiency in this scenario.

D. Delayed capillary refill is more often associated with arterial, not venous, insufficiency.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

New Nurse Statement	Met	Not Met
I will confirm the patient's pupil size with the scale on the side of the penlight.	✅
When putting the penlight at the bridge of the nose, the eyes converge and constrict	✅
I will check the patient's pupillary reflex by shining a light into their eyes.	✅
When shining the penlight into the patient's eyes, their pupils should dilate		✅

Rationale:

"I will confirm the patient's pupil size with the scale on the side of the penlight" (Met):

This is a correct use of the penlight to assess pupil size and document findings accurately.

"When putting the penlight at the bridge of the nose, the eyes converge and constrict" (Met):

This statement describes the normal accommodation reflex, where the eyes converge and pupils constrict when focusing on a near object.

"I will check the patient's pupillary reflex by shining a light into their eyes" (Met):

This correctly describes testing for the pupillary light reflex, where the pupil constricts in response to light.

"When shining the penlight into the patient's eyes, their pupils should dilate" (Not Met):

This is incorrect. The pupils should constrict in response to light, not dilate. Dilation occurs in response to low light or sympathetic stimulation.

A. Test for the Murphy sign B. Test for shifting dullness C. Perform the obturator test D. Test for the Blumberg sign E. Perform the iliopsoas muscle test F. Test for fluid wave

Correct Answer is ["C","D","E"]

Explanation

A. Murphy sign: This is used to assess for gallbladder inflammation, not appendicitis.

B. Shifting dullness: This is used to detect ascites, not appendicitis.

C. Obturator test: This test involves flexing the patient's right hip and knee and rotating the leg internally, causing pain if the appendix is inflamed.

D. Blumberg sign: This test for rebound tenderness indicates peritoneal irritation, commonly associated with appendicitis.

E. Iliopsoas muscle test: This test involves extending the right leg against resistance, which can elicit pain in cases of appendicitis.

F. Fluid wave: This is used to assess for ascites, not appendicitis.

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The nurse is performing an assessment on 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

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? (Select all that apply)

Correct Answer is ["C","D","E"]

Explanation

During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:

A nurse performs the Weber test on a healthy adult client. The nurse would expect which of the following normal finding?

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

When performing a peripheral vascular assessment of the lower extremities, a nurse should place the fingertips just posterior to the medial malleolus in order to assess for which of the following peripheral pulses?

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process?

The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?