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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Incorrect. Performing gastrostomy feedings is a complex task that requires specialized training and assessment skills. The nurse should not delegate this task to an AP who has not received the appropriate education and competency validation.

B. Correct. Determining if the PRN pain medication has helped is a simple task that involves asking the client about their pain level and documenting the response. The nurse can delegate this task to an AP as long as they follow up with the client and evaluate the effectiveness of the pain management plan.

C. Incorrect. Providing instructions about client care to a family member over the telephone is a task that requires clinical judgment and communication skills. The nurse should not delegate this task to an AP who might not have the knowledge or authority to answer questions or address concerns.

D. Incorrect. Teaching a client how to measure their own blood pressure is a task that requires teaching and evaluation skills. The nurse should not delegate this task to an AP who might not be able to explain the procedure, demonstrate the technique, or assess the client's learning.

A. Flex the client's neck forward. B. Group several nursing activities to be completed at one time. C. Limit suctioning the client's airway to 30 seconds at a time. D. Place the client in a quiet environment.

Correct Answer is D

Explanation

A. Flexing the client's neck forward can increase intracranial pressure by impeding venous drainage from the brain and increasing cerebral blood volume. Therefore, this choice is incorrect.

B. Grouping several nursing activities to be completed at one time can increase intracranial pressure by stimulating the client and causing fluctuations in blood pressure and heart rate. Therefore, this choice is incorrect.

C. Limiting suctioning the client's airway to 30 seconds at a time can reduce intracranial pressure by minimizing hypoxia and hypercarbia, which can cause cerebral vasodilation and increased cerebral blood volume. However, this intervention alone is not sufficient to prevent increased intracranial pressure, and suctioning should be done only when necessary and with caution. Therefore, this choice is partially correct but not the best answer.

D. Placing the client in a quiet environment can reduce intracranial pressure by minimizing sensory stimulation and promoting relaxation, which can lower blood pressure and heart rate and decrease cerebral metabolic demand. Therefore, this choice is correct and the best answer.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Correct Answer is B

Explanation

A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure (ICP)?

Correct Answer is D

Explanation

A nurse has received change-of-shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?

A nurse is teaching a prenatal class about infection prevention at a community centre. Which of the following statements by a client indicates an understanding of the teaching?

A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?

A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?