The nurse is checking peripheral perfusion to a child's extremity following a cardiac catheterization. Which assessment finding indicates adequate peripheral circulation to the affected extremity?
1. A capillary refill of greater than three seconds
2. A palpable dorsalis pedis pulse but a weak posterior tibial pulse
3. A decrease in sensation with a weakened dorsalis pedis pulse
4. A capillary refill of less than three seconds with palpable warmth
Correct 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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