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    Ati Nur3010 Health Assessment (ICHS College) Proctored Exam

    A nurse is assessing a client's peripheral perfusion by checking capillary refill. Which action should the nurse perform?

    Explanation & Rationale

    Rationale: A. Assessing skin temperature provides information about peripheral circulation but does not directly measure capillary refill. Temperature can be influenced by environmental factors and is a complementary assessment, not a replacement for the standard capillary refill technique. B. Palpating the nail bed with two fingers is unnecessary and may interfere with accurate assessment. Capillary refill is observational rather than a palpation-based test, so using one finger to apply gentle pressure is sufficient. C. Pressing on the patient’s fingernail until it blanches, then releasing and observing the time it takes for color to return, is the correct method for assessing capillary refill. Normal refill time is typically less than 2 seconds, indicating adequate peripheral perfusion and blood flow. This method provides a quick and noninvasive assessment of circulatory status. D. Elevating the hand to observe color is not a standard procedure for capillary refill assessment. Elevation can alter blood flow and may give misleading results, especially in patients with circulatory compromise or vascular disease.

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