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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Liver enlargement: Pain from liver enlargement is typically felt in the right upper quadrant, not along the costovertebral angle.
B. Spleen enlargement: Splenic pain is usually located in the left upper quadrant, not in the costovertebral area.
C. Ovarian infection: Pain from ovarian infection is typically felt in the lower abdomen or pelvis, not the back.
D. Kidney inflammation: Pain along the costovertebral angles often indicates kidney inflammation or infection, such as pyelonephritis.
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.
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