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.
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.

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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.

A. A client whose family requests hospital-based hospice care B. A client who requires transfer to a skilled care facility C. A client who qualifies for telehealth for pacemaker diagnostics D. A client whose caregiver requests adult day care services

Correct Answer is D

Explanation

A: Incorrect. Hospital-based hospice care is not a service provided by PACE, which is a program that offers comprehensive medical and social services to eligible older adults who wish to remain in their own homes and communities.

B: Incorrect. Transfer to a skilled care facility is not a goal of PACE, which aims to prevent or delay institutionalization by providing coordinated care and support to older adults with chronic conditions and functional limitations.

C: Incorrect. Telehealth for pacemaker diagnostics is not a specific service offered by PACE, which provides primary care, specialty care, prescription drugs, home health care, personal care, transportation, and other services as needed.

D: Correct. Adult day care services are part of the PACE program, which helps older adults maintain their independence and quality of life by providing socialization, supervision, and assistance with activities of daily living.

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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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