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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 B

Explanation

A. Stops any movement, and appears to listen for the sound: This does not relate to the corneal light reflex test.

B. Consider this a normal finding: Symmetric light reflection at the same clock position in both eyes indicates normal alignment of the eyes.

C. Shows no obvious response to the noise: This response is unrelated to the corneal light reflex test.

D. Shows a startle and acoustic blink reflex: This describes a normal response to a loud noise, not the corneal light reflex test.

A. Tympany to percussion over the intestines B. Loose, watery stool C. Suprapubic tenderness D. A non-palpable spleen E. Aortic pulsation in the epigastric area F. Decreased bowel sounds

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

Explanation

Each category must have at least 1 response option selected

Finding	Normal	Abnormal
Tympany to percussion over the intestines	✅
Loose, watery stool		✅
Suprapubic tenderness		✅
A non-palpable spleen	✅
Aortic pulsation in the epigastric area	✅
Decreased bowel sounds		✅

Rationale:

Tympany to percussion over the intestines (Normal):

Tympany is expected due to the presence of gas in the intestines.

Loose, watery stool (Abnormal):

This is indicative of diarrhea, which may point to gastrointestinal upset or infection.

Suprapubic tenderness (Abnormal):

Tenderness in this area may indicate bladder infection, inflammation, or pelvic issues.

A non-palpable spleen (Normal):

The spleen is generally not palpable in healthy individuals unless it is enlarged (splenomegaly).

Aortic pulsation in the epigastric area (Normal):

Mild pulsations may be felt in thin or normal-weight individuals. However, a widened or strong pulsation could suggest an abdominal aortic aneurysm.

Decreased bowel sounds (Abnormal):

Hypoactive or absent bowel sounds may indicate decreased intestinal motility, such as in ileus or peritonitis.

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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?

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Naxlex Comprehensive Predictor Exams

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:

Correct Answer is B

Explanation

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

Explanation

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The nurse is testing a patient's visual accommodation, which refers to which action?

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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?

Which of the following is the first important step in helping the patient to relax for the complete abdominal examination?

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