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?

A) Ask the patient about a history of frostbite.
B) Suspect that the patient has venous insufficiency.
C) Consider this a delayed capillary refill time, and investigate further.
D) Consider this a normal capillary refill time that requires no further assessment.

Question

Britney Hassan · Accepted Answer

Final Answer : C, Explanation :  Normal capillary refill time is less than 1 to 2 seconds. A capillary refill time of 5 is a decrease in capillary refill which indicates vasoconstriction or decreased cardiac output. The nurse should investigate further. Decreased capillary refill is not a characteristic of previous frostbite or venous insufficiency and some conditions can skew the findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.

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