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 A
Explanation
A. This choice is correct because a child who has autism spectrum disorder often exhibits strict adherence to routines and rituals, and may become distressed or agitated when there are changes or disruptions to their usual patterns.
B. This choice is incorrect because difficulty paying attention to tasks is not a specific manifestation of autism spectrum disorder, but rather a common symptom of attention-deficit/hyperactivity disorder (ADHD). A child who has autism spectrum disorder may have difficulty focusing on tasks that are not of interest to them, but may also show intense concentration on tasks that are of interest to them.
C. This choice is incorrect because disobedience to authority figures is not a specific manifestation of autism spectrum disorder, but rather a common behavior problem in children and adolescents. A child who has autism spectrum disorder may have difficulty understanding social cues and expectations, but may also show compliance and cooperation when given clear instructions and positive reinforcement.
D. This choice is incorrect because excessive anxiety when separated from parents is not a specific manifestation of autism spectrum disorder, but rather a common symptom of separation anxiety disorder. A child who has autism spectrum disorder may have difficulty forming attachments and expressing emotions, but may also show affection and attachment to familiar people.
Correct Answer is A
Explanation
Choice A reason:
Increased haemoglobin is correct. level Epoetin alfa is a medication used to stimulate the production of red blood cells in the bone marrow, and it is often prescribed to treat anaemia. Anaemia is characterized by a decrease in the number of red blood cells or a decrease in the amount of haemoglobin, which is responsible for carrying oxygen in the blood.
The therapeutic response to epoetin alfa is an increase in the haemoglobin level. This indicates that the medication is effectively stimulating the production of red blood cells, leading to an improvement in the client's anaemia and overall oxygen-carrying capacity of the blood.
Choice B reason:
Increased platelet count: Platelets are involved in blood clotting and are not directly affected by epoetin alfa.
Choice C reason:
Increased neutrophil count: Neutrophils are a type of white blood cell involved in the body's immune response. Epoetin alfa primarily affects red blood cells and does not directly impact white blood cell levels.
Choice D reason:
Increased erythrocyte sedimentation rate (ESR): ESR is a non-specific indicator of inflammation in the body and is not directly related to the therapeutic response of epoetin alfa in treating anaemia.
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