Reduction of Risk Potential Q 102

By | June 11, 2022

A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?
  
     A. Body temperature of 99°F or less
     B. Toes moved in active range of motion
     C. Sensation reported when soles of feet are touched
     D. Capillary refill of < 3 seconds
    
    

Correct Answer: D. Capillary refill of < 3 seconds

It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation.

Options A, B, and C: Body temperature, motion, and sensation would not give information regarding peripheral circulation.

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