The practical nurse (PN) applies and then releases pressure to a client's fingernail as seen in the photo. Normal nail color returns in 2 seconds. Which action should the PN take?

Report abnormal findings to the charge nurse.

Observe for blanching of the nailbed.

Repeat the process with a diﬀerent nailbed.

Document the capillary refill time.

Answer and Explanation

The Correct Answer is D

- Capillary refill time is a test that measures how quickly the blood returns to the tissues after pressure is applied and released on a nailbed or a fingertip. It is an indicator of peripheral circulation and tissue perfusion.
- To perform the capillary refill test, the examiner should press firmly on the nailbed or fingertip for a few seconds, then release the pressure and observe how long it takes for the normal color to return. The normal capillary refill time is less than 2 seconds .
- In the photo, the practical nurse (PN) applies and then releases pressure to a client's fingernail. Normal nail color returns in 2 seconds, which indicates a normal capillary refill time and adequate peripheral circulation. This is a normal and expected finding that does not require any further action, except for documentation.
- Therefore, option D is the correct answer, as it reﬂects the appropriate and standard nursing practice of documenting any assessment findings in the client's chart. Option D also implies that the PN does not need to report, observe, or repeat anything else related to the capillary refill test, as it was done correctly and yielded normal results.

- Options A, B, and C are incorrect answers, as they do not reﬂect the appropriate or necessary actions for the PN to take after performing a normal capillary refill test.

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Correct Answer is ["D","F","G"]

Explanation

Based on the provided information, the following components should be included in the treatment regimen for this client:

Oral anti-diabetic:
While oral medications are common in managing type 2 diabetes, the current information does not suggest immediate initiation of pharmacotherapy based solely on the random blood sugar result without further evaluation.
Weight-reduction treatment: With a BMI of 28, the client is considered overweight. Weight reduction is an important aspect of managing diabetes and improving overall health. The treatment regimen should include strategies to promote weight loss, such as dietary modifications and increased physical activity.
Exercise planning: Regular exercise is beneficial for managing diabetes and promoting overall health. The treatment regimen should include an exercise plan tailored to the client's abilities and preferences. This may involve aerobic exercises, strength training, and flexibility exercises.
Nutrition education: Nutrition plays a crucial role in diabetes management. The client should receive education on healthy eating habits, portion control, carbohydrate counting, and the importance of a balanced diet. The treatment regimen should include ongoing nutrition education and support.

The following options should not be included in the treatment regimen for this client:

Short-acting insulin: Based on the information provided, there is no indication for the immediate use of short-acting insulin in this client.
Long-acting insulin: Similar to short-acting insulin, there is no indication for the immediate use of long-acting insulin in this client.
Extra carbohydrates: Extra carbohydrates may not be necessary for this client unless prescribed by a healthcare professional to manage hypoglycemia or specific dietary needs.

A. Ask to see the client's list of home medications B. Determine if the client has recently lost a loved one C. Measure the client's vital signs D. Collect a sputum and urine culture and sensitivities E. Perform a 12-lead electrocardiogram F. Have the client ambulate across the room. G. Ask about the client's last bowel movement H. Measure the client's abdominal circumference

Correct Answer is ["A","B","C","E","H"]

Explanation

To identify the potential source of the client's new-onset confusion and decreased appetite, the nurse can use the following assessment techniques:

Ask to see the client's list of home medications: This can help identify any medications that may contribute to confusion or appetite changes.
Determine if the client has recently lost a loved one: Emotional distress, such as grief from a recent loss, can contribute to changes in mental status and appetite.
Measure the client's vital signs: Vital signs can provide important information about the client's overall health status and help identify any abnormalities that may be contributing to the symptoms.
Perform a 12-lead electrocardiogram: This can help assess the client's cardiac function and detect any cardiac-related causes for the symptoms.
Ask about the client's last bowel movement: Changes in bowel habits can sometimes be indicative of underlying issues affecting appetite and overall health.
Measure the client's abdominal circumference: This can help assess for any abdominal distension or changes that may be related to the client's symptoms.

Collecting a sputum and urine culture and sensitivities and having the client ambulate across the room are not directly related to identifying the potential source of confusion and decreased appetite in this case.

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The practical nurse (PN) applies and then releases pressure to a client's fingernail as seen in the photo. Normal nail color returns in 2 seconds. Which action should the PN take?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["D","F","G"]

Explanation

Exhibits here Review H and P and nurse's notes. What other assessment techniques can the nurse use to identify the potential source of the client's new-onset confusion and decreased appetite? Select all that apply.

Correct Answer is ["A","B","C","E","H"]

Explanation

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next?

In preparing to discontinue a client's saline lock, the practical nurse (PN) notes that the client is receiving an antiplatelet medication. Which action should the PN implement?

Before administering a scheduled dose of insulin to a 10-year-old child who is learning diabetic self-care, which information is most important for the practical nurse (PN) to ask the child?

Which intervention is the most important for the practical nurse (PN) to implement when applying an ice pack to a client?

The practical nurse (PN) should collect the following information during the admission assessment of a terminally ill client to an acute care facility:

The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using the thermometer. Which action should the PN take first?