The nurse is checking peripheral perfusion to a child's extremity following a cardiac catheterization. If there is adequate peripheral circulation, how should the extremity feel?
1. Cool, with a capillary refill of greater than 3 seconds
2. With a palpable dorsalis pedis pulse but an absent posterior tibial pulse
3. Decreased sensation, with an absent dorsalis pedis pulse
4. Warm, with a capillary refill less than 3 seconds
4
Rationale:
1. If the capillary refill takes more than 3 seconds, any of the pedal pulses are absent, or the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.
2. If the capillary refill takes more than 3 seconds, any of the pedal pulses are absent, or the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.
3. If the capillary refill takes more than 3 seconds, any of the pedal pulses are absent, or the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.
4. The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm, with capillary refill less than 3 seconds, has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pink color.
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