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Practice Question

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?

Answer Choices:

Correct Answer:

Document the capillary refill time.

Rationale:

✔️ The image shows the capillary refill test, a common method for evaluating peripheral perfusion and circulatory status.

✔️ A capillary refill time of 2 seconds or less is considered normal in adults and indicates that there is adequate blood flow to the extremities.

✔️ Since the nurse observes a refill time within normal limits, no further assessment is immediately necessary, and the finding should simply be documented.

✔️ There is no indication of circulatory compromise, so escalating care or repeating the test is unwarranted unless other signs of poor perfusion are present.

Educational Insight

Capillary refill is a quick bedside assessment used to evaluate tissue perfusion and cardiac output, especially in emergency and postoperative settings. It is typically done by pressing on the nailbed until blanching occurs, then releasing to see how quickly color returns. Delayed refill (>2 seconds) may indicate shock, dehydration, or peripheral vascular disease. Documenting normal findings ensures a reliable clinical baseline and supports continuity of care.

Want to practice more questions like this?

This question is from HESI PN EXIT (IV) which contains 149 questions.

More Practice Questions
In caring for a client who requires seizure precautions, the practical nurse (PN) should ensure the ready availability of equipment to perform which procedure?

Answer Choices:

A. Suction the trachea.
B. Insert a urinary catheter.
C. Apply soft restraints.
D. Insert a nasogastric tube.
The practical nurse (PN) is told that she keeps her 2-year-old child in a playpen so he will not get dirty. Which statement should the PN use in responding to this concern about using a playpen?

Answer Choices:

A. Overconcern about appearance can be harmful.
B. Playpens provide a sense of security for the child.
C. Playpens provide a safe environment for a toddler.
D. Children need time to actively explore their environment.
At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

Answer Choices:

A. "It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready."
B. "Would you like me to call another nurse to be here while I show you the wound?"
C. "Part of recovery is accepting your new body image, and you will need to look at your incision."
D. "You will feel better when you see that the incision is not as bad as you may think."
Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?

Answer Choices:

A. Administer the medication and alert the charge nurse.
B. Hold the medication and document cardiac assessment.
C. Administer the medication and document the heart rate.
D. Hold the medication and recheck the heart rate in 1 hour.
From Exam
HESI PN EXIT (IV)

149 Questions

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Question Details
  • Category: LPN - Nursing Exam(s)
  • Subcategory: Exit Exams
  • Domain: HESI Exit - LPN
  • Answer Choices: 4
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