Which of the following is an abnormal capillary refill finding ...

[jasdeep_brar]

Which of the following is an abnormal capillary refill finding that the nurse should report?
 
  a. 1 second
  b. 2 seconds
  c. 3 seconds
  d. 4 seconds

Question 2

The nurse is caring for a group of patients on the medical-surgical unit. The most important action the nurse can take in preventing falls is:
 
  a. Use two siderails for each patient's bed
  b. Place a fall risk sign on the front of the patient's door
  c. Identify those patients who are at risk for falls
  d. Use wrist restraints for any confused or combative patient

[at]

Answer to Question 1

D
Normal capillary refill is less than 3 seconds; therefore, the nurse should report a capillary refill of 4 seconds.

Answer to Question 2

C
Perhaps the single most important thing a nurse can do to prevent falls is to identify those who are at risk for falls. This should be done on the initial admitting assessment and throughout the patient's hospitalization. Once a fall risk is identified, there are many mechanisms put in place to alert others to fall risk. Mechanisms such as special colored armbands and placing signs on the patient's door are commonly used. The use of siderails has not been shown to prevent falls, as patients commonly climb over them. Use of wrist restraints on a confused or combative patient may be helpful in preventing falls; however, restraints are used as a last resort.