The nurse is checking peripheral perfusion to a child's extremity following a cardiac catheterization. If there is adequate peripheral circulation,the nurse would find that the extremity
1. has a capillary refill of greater thanthree seconds.
2. has a palpable dorsalis pedis pulsebut a weak posterior tibial pulse.
3. has decreased sensation with aweakened dorsalis pedis pulse.
4. is warm,with a capillary refill of lessthan three seconds.
Answer:4
Rationale: The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than three seconds has adequate circulation.Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses,adequate sensation,and pinkness of skin color.If the capillary refill is over three seconds;if any of the pedal pulses are absent and/or weakened;or if the extremity is cool, cyanotic,or lacking sensation,circulation may not be adequate.
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