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 ["A","D","E"]
Explanation
Rationale:
A. Open-ended questions are designed to encourage the client to provide detailed, descriptive responses rather than simple yes/no or one-word answers. This helps the nurse gain a deeper understanding of the client’s health status, concerns, and experiences.
B. This is characteristic of closed-ended questions, not open-ended questions. Closed-ended questions limit the client’s response to brief, factual answers and do not provide the same depth of information.
C. Open-ended questions are intended to elicit detailed and narrative responses, not just simple or direct answers. Therefore, this statement is inaccurate.
D. Open-ended questions give clients the opportunity to express their priorities, feelings, and concerns, which may reveal important information that might not be captured through structured or closed-ended questions.
E. By allowing clients to speak freely and feel heard, open-ended questions foster trust and a therapeutic nurse-client relationship. This promotes effective communication and client engagement.
Correct Answer is A
Explanation
Rationale:
A. This is a critical finding that indicates possible pressure injury (pressure ulcer) or tissue ischemia. Non-blanching means that when pressure is applied, the area does not turn white, which is a hallmark sign of compromised perfusion and potential skin breakdown. Immediate reporting is necessary to prevent further tissue damage and initiate interventions such as pressure relief, wound care, and close monitoring.
B. This is an old, healed injury and is considered normal in the context of a skin assessment. It does not indicate current skin compromise and does not require urgent reporting.
C. Freckles are benign pigmented skin lesions. They are normal variations in skin pigmentation and do not indicate acute pathology or require immediate reporting.
D. While dry skin should be addressed to prevent discomfort or cracking, it is not an urgent finding. It can be managed with routine skin care and moisturizer, and does not require immediate intervention.
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