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.

Question

Quizplus · Accepted Answer

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.

The Nurse Tests the Capillary Refill on a Client's Lower