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
Choice A reason:
A. Natal Infant Pain Scale (NIPS): The NIPS is a behavioral assessment tool designed for both preterm and full-term neonates. It evaluates six behavioral indicators in response to painful procedures. These indicators include changes in facial expression (such as grimacing, brow bulge, and eye squeeze), body movements (such as fisting, tremulousness, and limb withdrawal), and other signs of distressChoice B reason:
FACES pain rating scale The FACES pain rating scale should not be used because it is a visual scale that uses facial expressions to assess pain in children who can communicate using pictures of faces displaying different emotions. It is generally used for older children and not appropriate for newborns.
Choice C reason
Premature Infant Pain Profile (PIPP): The PIPP is another pain assessment tool specifically developed for preterm infants. It considers physiological and behavioral parameters, including facial expressions, heart rate, oxygen saturation, and gestational age. While useful for preterm infants, it may not be the best choice for full-term newborns.Since the newborn in this scenario was delivered at 38 weeks of gestation, the PIPP would be an appropriate pain assessment tool to use. It considers specific physiological and behavioural indicators of pain in newborns and helps healthcare providers evaluate and manage pain in this vulnerable population.
Choice D reason:
Visual analog scale (VAS) should not be used because the visual analog scale is a pain assessment tool typically used for older children, adolescents, and adults who can understand and provide a subjective rating of their pain intensity along a linear scale. It involves marking a point on the line corresponding to the level of pain experienced. Since newborns cannot communicate in this way, the VAS is not suitable for their pain assessment.
Correct Answer is B
Explanation
A. Incorrect. Measuring the group's work against the assigned objectives is a task role that belongs to the evaluator, who assesses the quality and effectiveness of the group's performance.
B. Correct. Noting the progress of the group toward assigned goals is a task role that belongs to the orienteer, who keeps track of where the group is heading and summarizes what has been accomplished.
C. Incorrect. Sharing experiences as an authority figure is a task role that belongs to the information giver, who provides factual data or personal knowledge to the group.
D. Incorrect. Offering new and fresh ideas on an issue is a task role that belongs to the initiator, who proposes new solutions or approaches to problems.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today