Ati nurs220 health assessment proctored exam
The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?
Explanation & Rationale
A. Capillary refill time greater than 2 seconds is abnormal and requires further assessment. B. A capillary refill time of 5 seconds indicates delayed peripheral perfusion and warrants further investigation. C. While frostbite can cause delayed refill, it is less likely than vascular insufficiency in this scenario. D. Delayed capillary refill is more often associated with arterial, not venous, insufficiency.
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