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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 C

Explanation

A. High-pitched, tinkling sounds: These may indicate bowel obstruction, not expected immediately after surgery.
B. Normal bowel sounds: Normal bowel sounds usually return gradually after surgery, but are unlikely within the first 24 hours.
C. Hypoactive bowel sounds: It is common to hear hypoactive or diminished bowel sounds in the first 24-48 hours after abdominal surgery due to postoperative ileus.
D. Hyperactive bowel sounds: These suggest increased peristalsis and are not typical immediately after surgery.

A. Six B. Four C. Eight D. Nine

Correct Answer is B

Explanation

A. Six: The abdomen is typically not divided into six sections.

B. Four: Most healthcare providers divide the abdomen into four quadrants: right upper, left upper, right lower, and left lower.

C. Eight: Eight sections are not commonly used for abdominal assessment.

D. Nine: Nine sections are used in more detailed assessments but are less common than the four-quadrant approach.

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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

A patient had abdominal surgery yesterday when auscultating his abdomen, you would expect to hear:

Correct Answer is C

Explanation

When assessing the abdomen most health care providers divide the abdomen into how many sections?

Correct Answer is B

Explanation

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