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
Explanation
A. This emphasizes recognizing abnormal findings, such as an enlarged testicle or a painless lump, which may indicate testicular cancer.
B. Testicles are smooth, firm, and egg-shaped but should not have a lumpy consistency.
C. Monthly, not weekly, self-examinations are recommended for early detection.
D. The best time to examine is during or after a warm shower when the scrotum is relaxed, not before.
Correct Answer is D
Explanation
A. Smallest speculum: The smallest speculum may not provide the best view of the ear canal and tympanic membrane, especially in adults. The correct size should be chosen for adequate visualization.
B. Releasing the traction: Traction should be maintained to stabilize the ear and allow a better view of the ear canal.
C. Tilting the person's head forward: This is not the ideal positioning for the ear examination. The head should be tilted slightly away to straighten the ear canal.
D. Pulling the pinna up and back: This helps straighten the ear canal, especially in adults, providing better visualization during the otoscopic examination.
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