Question

A nurse is assessing a client's capillary refill. Which action would be most appropriate?

a) Bend the client's foot up toward the leg
b) Check the apical and radial pulses simultaneously
c) Press on the nail bed until is blanches
d) Note localized skin discolorations

Answer 1

The most appropriate action for assessing capillary refill is to press on the nail bed until it blanches and observe the time it takes for the color to return, which indicates the adequacy of blood circulation.

Step-by-step explanation:

The most appropriate action for assessing a client's capillary refill would be to press on the nail bed until it blanches. This is often referred to as a blanch test and provides a quick and reliable indicator of blood circulation to the extremities and the overall oxygen saturation of the blood. The nail bed should turn white when pressure is applied, and once the pressure is released, the pink color of the nail bed should return within one to two seconds if blood flow is adequate. Should there be a delayed return to a pink color, this can be an indicator of issues such as low blood volume, dehydration, or shock. Assessing capillary refill is a simple yet vital action that can provide important information about a patient's circulatory health.