2024 HESI PN Exit Exam V2 New Latest Version with All
Questions from Actual Past Exams and 100% Correct
Answers and Rationale
Question 1:
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?
A. Report abnormal findings to the charge nurse.
B. Observe for blanching of the nailbed.
C. Repeat the process with a different nailbed.
D. Document the capillary refill time.
Show correct answer and explanation
Explanation
- 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.
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