When checking a client's capillary refill, the nurse finds that the color returns in 10 seconds. The nurse should understand that this finding indicates which of the following?

Within the expected range

Venous insufficiency

Thrombus formation in the vein

Arterial insufficiency

Answer and Explanation

The Correct Answer is D

A. Normal capillary refill time is less than 2 seconds. A 10-second refill is significantly delayed and not within the expected range.
B. Venous insufficiency typically presents with symptoms like edema, varicosities, and skin changes, but it does not usually cause delayed capillary refill.
C. A venous thrombus may cause swelling and discomfort, but it does not typically lead to prolonged capillary refill.
D. A prolonged capillary refill time (greater than 2 seconds) indicates poor arterial perfusion, suggesting arterial insufficiency, which impairs oxygenated blood flow to the extremities.

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Correct Answer is C

Explanation

A. A low-sodium diet is appropriate for many cardiac clients and does not conflict with pacemaker placement.
B. Physical therapy is generally safe and beneficial, especially with guidance to avoid lifting the arm on the operative side above shoulder level initially.
C. MRI is contraindicated or used with caution in clients with a pacemaker, especially if it's not MRI-compatible, due to potential interference with device function.
D. Monitoring cardiac enzymes may be necessary postoperatively or if myocardial injury is suspected.

Correct Answer is ["28"]

Explanation

Ordered dose: 28 units
Available concentration: 100 units/mL

Step 1: Use the formula
mL to give = (Desired dose ÷ Concentration)

mL to give = 28 ÷ 100
mL to give = 0.28 mL

Step 2: Convert back to units
Since insulin is measured and administered in units, and the order is already in units:

Final Answer: 28 units

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When checking a client's capillary refill, the nurse finds that the color returns in 10 seconds. The nurse should understand that this finding indicates which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following orders should the nurse clarify?

Correct Answer is C

Explanation

The physician orders insulin lispro 28 units subcutaneous. The medication is supplied in 100 units/mL. How many units will the nurse administer?

Correct Answer is ["28"]

Explanation

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