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 {"A":{"answers":"D"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"}}
Explanation
Assessment Technique |
1 |
2 |
3 |
4 |
Percussion |
✅ |
|||
Inspection |
✅ |
|||
Palpation |
✅ |
|||
Auscultation |
✅ |
Rationale:
Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
Correct Answer is B
Explanation
A. 1 minute: This is not the correct duration for assessing bowel sounds.
B. 2 minutes each quadrant: Bowel sounds should be auscultated for at least 2 minutes per quadrant before determining that they are absent.
C. 5 minutes: Listening for 5 minutes is excessive and typically unnecessary unless there is concern about a complete absence of bowel sounds.
D. 10 minutes: 10 minutes is also too long for auscultation unless specifically indicated by clinical findings, like suspected paralytic ileus.
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