The nurse is concerned that a client with a fluid imbalance is at risk for an alteration in perfusion. Which assessment data indicates that the client is experiencing an alteration in perfusion?

Question

Select all that apply.
A) Skin turgor 20 seconds
B) Peripheral pulses present and full
C) Capillary refill of nail beds 3 seconds
D) Oriented to person, place, and time
E) Bowel sounds sluggish in all four quadrants

Answer 1

Answer: B, C, D

In clients with an altered fluid balance, there is a risk of developing an alteration in perfusion. To determine whether the client's perfusion status is being affected, the nurse should assess pulses, nail beds, and orientation. Full and present peripheral pulses, capillary refill of 3 seconds, and oriented to person, place, and time indicate that the client's perfusion status is being maintained. Skin turgor and bowel sounds would be used to determine whether the fluid imbalance is affecting the client's elimination status. Skin turgor that takes 20 seconds to return to normal and sluggish bowel sounds indicate that the fluid imbalance is affecting the client's elimination status.