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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Troponin I is a cardiac-specific biomarker that begins to rise within 2 to 3 hours after myocardial injury, peaks at 24 hours, and remains elevated for 5–10 days. It is the most sensitive and specific indicator of myocardial infarction.
B. Serum amylase is associated with pancreatic disorders, not myocardial infarction.
C. Unconjugated bilirubin is related to liver function or hemolysis, not cardiac injury.
D. AST can rise after an MI but is not cardiac-specific and is less reliable than troponin for diagnosing MI.
Correct Answer is D
Explanation
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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