Patient Data

The client with a cast must have a neurovascular assessment every hour for the first 24 hours and then every 4 to 8 hours after the cast has dried. Assessment of the skin, movement, sensation, pulses, pain and capillary refill are areas of concern.
When assessing the client's capillary refill status, which steps should the practical nurse (PN) include in the procedure? Select all that apply.

Normal should be within 3 seconds or 5 seconds in the older adult

Use your thumbnail and press the nailbed proximal to the injury

Capillary refill is measured in seconds

Pressure placed on the nailbed should cause blanching

Capillary refill is the time it takes to return to the client's normal color after releasing pressure

Answer and Explanation

Correct Answer : C,D,E

Rationale:

A. Normal should be within 3 seconds or 5 seconds in the older adult: While refill times can slow slightly with age, the standard clinical benchmark for a "normal" capillary refill is less than 2 seconds. In a fresh fracture and cast, a 4-second refill is a critical finding suggesting impaired peripheral perfusion

B. Use your thumbnail and press the nailbed proximal to the injury: Applying pressure with the thumbnail can cause unnecessary discomfort or injury, especially near a fractured limb. The standard technique is to press directly on the nailbed with a fingertip to avoid trauma while still effectively assessing perfusion.

C. Capillary refill is measured in seconds: Measuring the refill in seconds allows the nurse to quantify the perfusion and detect early signs of compromised circulation, which is critical for timely intervention in a client with a new cast and risk of neurovascular compromise.

D. Pressure placed on the nailbed should cause blanching: Blanching occurs when blood is temporarily displaced from the capillaries. Observing this response ensures that the capillary refill can be accurately timed, providing an objective assessment of blood flow distal to the fracture site.

E. Capillary refill is the time it takes to return to the client's normal color after releasing pressure: This step is the essence of the capillary refill test. It reflects the speed of arterial blood return, which is a vital indicator of adequate peripheral perfusion and early detection of circulatory compromise under a cast.

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Correct Answer is A

Explanation

Rationale:

A. Position the client on the left side and reassess: Placing the client in the left lateral decubitus position shifts the heart closer to the chest wall, making the PMI easier to palpate, especially in older adults or clients with a thick chest wall. This maneuver is a standard initial approach to improve assessment accuracy before concluding that the apical site is non-palpable.

B. Document the lack of an apical pulse in the medical record: Recording a missing apical impulse without further assessment is premature. The inability to palpate the PMI in the supine position can be influenced by positioning or body habitus, additional assessment techniques should be attempted first.

C. Assess the client for signs of diminished cardiac output: While important for overall cardiac assessment, evaluating for symptoms such as hypotension, fatigue, or altered mentation does not address the immediate issue of locating the PMI. This action is supportive but not the priority initial step.

D. Count the pulse rate and volume at the radial site: Measuring the radial pulse provides information on peripheral perfusion but does not substitute for assessing the apical impulse, which is critical for detecting dysrhythmias or confirming heart rate and rhythm, particularly in a bedfast client.

A. Inspect the urethral meatus for discharge. B. Observe the scrotum for swelling. C. Palpate the inguinal area for a bulge. D. Question client about urinary dribbling and frequency.

Correct Answer is D

Explanation

Rationale:

A. Inspect the urethral meatus for discharge: Examining the urethral meatus is primarily indicated when infection or inflammation, such as urethritis, is suspected. While discharge could indicate a problem, the client’s main concern involves urinary hesitancy and nocturia, making this assessment less directly relevant.

B. Observe the scrotum for swelling: Scrotal inspection is important for conditions such as hydrocele or testicular masses. These findings are not typically associated with nocturia or difficulty initiating urination in older males, so this assessment would not provide focused information for the client’s current urinary symptoms.

C. Palpate the inguinal area for a bulge: Assessing the inguinal area can detect hernias, which may cause discomfort or urinary issues indirectly, but it does not address the primary complaints of urinary hesitancy and frequency, and is therefore not the most pertinent assessment.

D. Question client about urinary dribbling and frequency: Asking about urinary dribbling, frequency, and stream characteristics directly evaluates symptoms associated with benign prostatic hyperplasia or lower urinary tract obstruction. This focused history provides critical information to guide further assessment and intervention for the client’s nocturia and difficulty initiating urination.

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) wants to assess heart sounds at the apical site of a bedfast client who is lying in a supine position. The PN is unable to palpate the PMI (point of maximal impulse). Which is the best initial nursing action?

Correct Answer is A

Explanation

An older adult male client reports nocturia with difficulty starting his urine stream. Which focused assessment should the practical nurse (PN) perform to obtain further information?

Correct Answer is D

Explanation

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