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.
Option A is incorrect because there are no abnormal findings to report to the charge nurse, as the capillary refill time was normal.
Option B is incorrect because blanching of the nailbed is what happens when pressure is applied, not when
it is released, and it is not an abnormal finding.
Option C is incorrect because repeating the process with a different nailbed is not necessary, as the capillary refill time was normal on the first nailbed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
"I will avoid using my microwave oven at home because of the ICD."This statement is incorrect. Using a microwave oven does not interfere with the functioning of an ICD. It is safe for clients with ICDs to use microwave ovens.
Choice B reason:
"I can hold my cell phone on the same side of my body as the ICD."This statement is incorrect Holding a cell phone on the same side of the body as the ICD should not cause any harm or interfere with the device's functioning.
Choice C reason:
"I will wear loose clothing over my ICD." This statement is correct and demonstrates understanding of the teaching. Wearing loose clothing over the ICD helps prevent excessive pressure or friction on the device and reduces the risk of dislodging the ICD leads or causing discomfort.
Choice D reason:
"I will soak in the tub rather than showering." This statement is incorrect. Avoiding showers is not necessary for clients with ICDs. Taking showers is generally safe for individuals with ICDs, as the device is designed to be waterproof and withstand such conditions.
Correct Answer is C
Explanation
A. Documenting the client's refusal in the medical record is an important action, but not the first one. The nurse should first try to understand the client's perspective and address any concerns or misconceptions they might have about the blood transfusion. This choice is incorrect.
B. Honoring the client's decision to refuse the blood transfusion is a respectful and ethical action, but not the first one. The nurse should first attempt to educate and persuade the client about the benefits and risks of the treatment, and respect their autonomy only after ensuring that they have made an informed decision. This choice is incorrect.
C. Exploring the client's reasons for refusing the treatment is the first action that the nurse should take. The nurse should use effective communication skills to elicit the client's beliefs, values, fears, and preferences regarding the blood transfusion, and provide factual and evidence-based information to address any knowledge gaps or misconceptions. The nurse should also assess the client's decision-making capacity and determine if they are competent to refuse the treatment. This choice is correct.
D. Discussing the client's refusal with the provider is an appropriate action, but not the first one. The nurse should first try to resolve the issue with the client directly, and involve the provider only if they are unable to do so or if there are legal or ethical implications that require further consultation. This choice is incorrect.
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