The nurse tests the capillary refill on a client's lower extremity and notes that it takes 4 seconds for the color to return to baseline. It would be most important for the nurse to then check for
a. constricting clothing.
b. other indicators of peripheral perfusion.
c. presence of venous ulcers.
d. prior surgery on this extremity.
B
Capillary refill time is an evaluation of peripheral perfusion and cardiac output. Normal is up to 3 seconds; 4 seconds is too slow, so the nurse should do further assessments of peripheral perfusion. Certainly constrictive clothing might be a problem, but that would be considered as part of the peripheral perfusion assessment. Venous ulceration is also part of an assessment of peripheral perfusion. Prior surgery may or may not be related.
You might also like to view...
A four-year-old child is being emotionally prepared for open heart surgery. The nurse will want to provide the child with which information?
1. Who will be performing the surgery 2. What the surgical procedure will entail 3. The purpose of the heart-lung machine 4. What the ICU will look and sound like when the child wakes up
The nurse is caring for a client who is hospitalized with pneumonia. Which will the nurse assess when determining the impact of the illness on the family? Select all that apply
A) The duration of the illness B) The effect of the illness on future family functioning C) The cause of the illness D) The meaning of the illness to the family E) The financial impact of the illness
A nurse explains to a nursing student why opioid antidiarrheal medications are classified as drugs with little or no abuse potential. Which statement by the student indicates a need for further teaching?
a. "Formulations for the treatment of diarr-hea have very short half-lives." b. "Opioid antidiarrheal drugs contain other drugs with unpleasant side effects at higher doses." c. "Some opioid antidiarrheal drugs do not cross the blood-brain barrier." d. "Some opioid antidiarrheal medications are not water soluble and cannot be given parenterally."
The nurse is planning postop care for an infant after a cleft lip repair. The plan should include:
1. Prone positioning. 2. Suctioning with a Yankauer device. 3. Supine or side-lying positioning. 4. Avoidance of soft elbow restraints.