6. A 28-year-old client is admitted to an intensive care unit (ICU) following a construction accident. Which assessment finding requires an immediate response by a nurse?
6. A 28-year-old client is admitted to an intensive care unit (ICU) following a construction accident. Which assessment finding requires an immediate response by a nurse?
. Extremities warm and dry.
. Temperature 100°F (37.8°C).
. Urinary output 100 mL/hr.
. Extremity capillary refill 5 seconds.
Test-Taking Tip
Three options are "OK" findings; one option is not an "OK" sign. Use a process of elimination to narrow down the options to the one that is a problem finding.
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
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Answer 1 is incorrect because warm and dry indicates perfusion. Answer 2 is incorrect because this is not a significant elevation. Answer 3 is incorrect because this is within the normal range. Answer 4 is correct because this is too slow and peripheral blood flow is sluggish, indicating impaired circulation. Normal reperfusion occurs in 3 seconds.