A nurse has assessed a patient's capillary refill, which was 5 seconds. What action by the nurse is most appropriate?
a. Document the findings and continue the examination.
b. Ask the patient about the use of artificial nails.
c. Ask the patient about his/her occupation.
d. Assess the patient for signs of hypoxia.
ANS: D
Normal capillary refill is 2 to 3 seconds. Prolonged capillary refill can indicate hypoxia, anemia, or circulatory insufficiency. The nurse should document the findings, but further action is not needed. Asking about artificial nails and occupation are not warranted.
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