What is the normal time for capillary refill in a healthy adult when assessing peripheral circulation?
3 to 5 seconds
Less than 2 seconds
More than 5 seconds
10 seconds
The Correct Answer is B
Rationale:
A. A capillary refill time of 3 to 5 seconds is longer than normal and may indicate poor peripheral perfusion, dehydration, shock, or circulatory compromise. This is considered abnormal and requires further assessment.
B. Less than 2 seconds is normal capillary refill time for healthy adults. It indicates that peripheral circulation is adequate, and blood is returning quickly to the capillaries after blanching. This measure is a simple, noninvasive way to assess tissue perfusion and cardiovascular function.
C. More than 5 seconds is abnormal and often signals impaired peripheral circulation. Causes can include hypovolemia, heart failure, or peripheral vascular disease. This finding warrants prompt evaluation and intervention.
D. A capillary refill time of 10 seconds is significantly prolonged and indicates severe compromise of peripheral perfusion. It is abnormal and may reflect shock, severe dehydration, or circulatory failure, requiring urgent assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Step 1: Identify desired dose and concentration
Desired dose = 50 mg, Concentration = 25 mg/mL
Step 2: Use the formula
Volume (mL) = Desired dose ÷ Concentration
Step 3: Insert values
= 50 ÷ 25
Step 4: Calculate
= 2 mL
Final Answer: 2
Correct Answer is A
Explanation
Rationale:
A. Clubbing of the fingernails is a physical sign characterized by enlargement of the distal fingers and a loss of the normal angle between the nail and nail bed. It is most commonly associated with chronic hypoxia, which occurs in conditions such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, congenital heart disease, or interstitial lung disease. Chronic low oxygen levels trigger changes in the soft tissue beneath the nail bed, leading to the clubbed appearance.
B. Dehydration affects fluid balance and skin turgor but does not cause nail clubbing. Signs of acute dehydration include dry mucous membranes, decreased skin turgor, and hypotension, rather than changes in nail morphology.
C. Sinusitis is an acute or chronic inflammation of the sinuses. While it may cause facial pain, nasal congestion, or fever, it does not lead to clubbing of the nails, as it does not chronically affect oxygenation.
D. Iron deficiency anemia may cause koilonychia (spoon-shaped nails), pallor, or brittle nails, but it is not associated with clubbing. Koilonychia presents differently, with thin, concave nails rather than the bulbous enlargement seen in clubbing.
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