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. Constipation: This involves hardened stool in the colon, causing localized distention but no free fluid.
B. Splenomegaly: Enlargement of the spleen causes a palpable mass in the left upper quadrant but no free fluid.
C. Distended bladder: This causes suprapubic distension but does not produce a fluid wave.
D. Ascites: A positive fluid wave test indicates free fluid in the abdominal cavity, a hallmark sign of ascites. The test is performed by tapping one side of the abdomen and observing for a wave-like transmission of fluid to the opposite side.
Correct Answer is A
Explanation
A. Posterior tibial: The posterior tibial pulse is palpated just posterior to the medial malleolus (inner ankle).
B. Femoral: The femoral pulse is assessed in the groin area, not near the ankle.
C. Popliteal: The popliteal pulse is located behind the knee, not near the ankle.
D. Dorsalis pedis: The dorsalis pedis pulse is palpated on the top of the foot, not near the ankle.
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