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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Pilocarpine ophthalmic drops are used to treat glaucoma by reducing intraocular pressure. They do not have an anesthetic effect and are not used for the purpose of numbing or anesthetizing the eyes. It is important for the client to have a correct understanding of the medication and its intended use.
Here's why the other options are incorrect:
A. Reassure the client that the drops will not be needed often since eye pain in glaucoma is not common: This statement is not accurate. While eye pain may not be a common symptom of glaucoma, pilocarpine drops are primarily used to reduce intraocular pressure, not to address eye pain.
B. Reteach the client about the action of the eye drops to decrease pressure in the eyes: This option may be considered if the client misunderstood the information initially, but it is not the most appropriate response in this scenario. The client's statement indicates a specific belief about the drops providing anesthetic effects, so clarifying the purpose of the drops is more appropriate.
C. Document in the chart that the client understands the action and use of the eye drops: Documentation is important, but in this case, it is necessary to address the client's misconception about the anesthetic effect of the drops and provide accurate information.
Correct Answer is A
Explanation
The action the practical nurse (PN) should take in this situation is to administer a prescribed PRN (as needed) dose of analgesic.
Severe burning pain along the right side of the trunk is a common symptom of herpes zoster (shingles). Managing the client's pain is an important aspect of care to provide comfort and promote healing. Administering a prescribed PRN dose of analgesic will help alleviate the client's pain and improve their overall well-being. It is crucial to follow the client's prescribed medication regimen and provide pain relief as needed.
The other options are not the most appropriate actions in this situation:
B. Notifying the nursing supervisor of uncontrolled pain may be necessary if the client's pain persists despite appropriate interventions. However, the first step should be to administer an analgesic to address the immediate pain.
C. Giving the next prescribed dose of antiviral medication is important in the treatment of herpes zoster, but it does not directly address the client's current severe burning pain. Analgesics are specifically designed to alleviate pain symptoms.
D. Obtaining an oxygen tank for home administration is not indicated for the management of pain associated with herpes zoster. Oxygen therapy is typically used for respiratory or circulatory conditions and would not be the appropriate intervention for the client's symptom of severe burning pain.
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