OXYGENATION AND PERFUSION N...

NCLEX style questions: Perfusion

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OXYGENATION AND PERFUSION N...

22 terms josemisael_hernand... Preview Perfusi 41 terms Han A​ 65-year-old client presents to the emergency department with a​ 3-day history of diarrhea and vomiting. The nurse notices that the​ client's pulse is 128 bpm. What is the most likely cause of the increased heart​ rate?

• Dehydration from loss of fluids
• The​ client's age
• Stress from being sick
• Effects of medications the client has taken
• Dehydration from loss of fluids

A client has been diagnosed with borderline hypertension and is given a blood pressure monitor to take daily BP readings. What instructions would be appropriate for the nurse to give the client for taking home blood​ pressure?

• ​"Take blood pressure at different times every day to be sure it is not elevated at different times of the​ day."
• ​"Blood pressure should be taken before getting up in the​ morning, with the arm elevated over the level of the​ heart."
• ​"Rest for at least 5 minutes before taking blood pressure and at least 30 minutes after drinking caffeinated​ beverages."
• ​"Blood pressure readings will be erroneously high if the arm is above the level of the​ heart."
• ​"Rest for at least 5 minutes before taking blood pressure and at least 30 minutes after drinking caffeinated​ beverages."

A​ 45-year-old client has been diagnosed with hypertension. Which modifiable risk factor would the nurse​ assess?

• Family History
• Age
• Stress
• Sex
• Stress

A surgical client is admitted to the ICU following abdominal surgery. Which clinical manifestation would the nurse recognize as an indication of decreased cardiac​ output? (Select all that​ apply.)

• Lethargy
• Increased pulse rate
• Capillary refill less than <3 seconds
• Decreased urine output
• Palpable pedal pulses
• Lethargy
• Increased pulse rate
• Decreased urine output

A client appears anxious and nervous upon entering the healthcare​ provider's office. The nurse takes a blood pressure reading and notes that it is elevated. What is the next appropriate action the nurse should​ take?

• Have the client rest quietly for 5 minutes and retake the blood pressure.
• Ask the client to tell you her usual blood pressure.
• Document the blood pressure and tell the physician the client is anxious.
• Instruct the client to calm down so accurate vital signs can be obtained.
• Have the client rest quietly for 5 minutes and retake the blood pressure.

A nurse obtains a​ client's radial pulse and notes that it is rapid and very irregular. What is the most appropriate action for the nurse to​ take?

• Have the client lie still for 5 minutes and attempt another measurement.
• Obtain an apical pulse for 1 minute.
• Document the best estimation of the pulse.
• Ask another nurse to attempt a radial pulse measurement.
• Obtain an apical pulse for 1 minute.

A​ 62-year-old female client has been diagnosed with narrowing of the coronary arteries. What would be the​ appropriate, conservative initial treatment for this​ condition?

• Eat a diet with a minimum of​ 20% fat.
• Take statin medications as prescribed.
• Exercise for 30 minutes 3 times a week.
• Cut smoking by half the usual amount.
• Exercise for 30 minutes 3 times a week.

A nurse is performing an assessment on a​ 65-year-old client. Which subjective assessment finding could indicate a decrease in​ perfusion?

• Sleeping with more pillows or in a recliner
• Nocturnal leg cramping
• Reporting the need for a​ mid-afternoon nap
• Decreased appetite
• Sleeping with more pillows or in a recliner

The nurse is obtaining an apical pulse in an infant. What is the best site for the nurse to place the​ stethoscope?

• At the left nipple at the 4th intercostal space
• At the right nipple just above the 3rd intercostal space
• Just below the clavicle between the 1st and 2nd intercostal space
• In the left​ mid-axillary area at the 4th intercostal space
• At the left nipple at the 4th intercostal space

Which is most likely to be a normal assessment finding in an​ 80-year-old client?

• Blood pressure of​ 160/90 mmHg
• Resting heart rate of 62​ beats/min
• Irregular heart rhythm
• Heart rate of 110​ beats/min
• Resting heart rate of 62​ beats/min

Which independent nursing intervention would be most beneficial for a client who experiences extreme shortness of breath with​ activity?

• Promoting relaxation techniques
• Dietary teaching
• Elevating lower extremities to prevent edema
• Administering increased oxygen as needed with activity
• Promoting relaxation techniques

The nurse is teaching a client with poor peripheral perfusion about the purpose of compression stockings. Which response by the nurse would be​ accurate?

• ​"You will notice that your skin will improve with the use of these stockings as they help protect your skin from​ injury."
• ​"These stockings will help to keep your blood pressure​ elevated, especially when you stand too​ quickly."
• ​"You will find that these stockings will help the heart pump more efficiently and increase the circulation to your lower​ extremities."
• ​"These stockings will be helpful in preventing the blood from pooling in your lower extremities and help prevent any clots from​ forming."
• ​"These stockings will be helpful in preventing the blood from pooling in your lower extremities and help prevent any clots from​ forming

An client who is obese and who has a history of heart disease and heart failure​ (HF) is in an intensive care unit. The client is having a very difficult time getting comfortable in bed. The client has difficulty sleeping and becomes short of breath upon lying down in bed. Which nursing intervention could help promote​ comfort?

• Increasing the​ client's oxygen at night
• Elevating the head of the bed and providing extra pillows
• Advising family to stay with the client at night
• Obtaining an order for a sleeping pill
• Elevating the head of the bed and providing extra pillows

A​ 70-year-old client is ambulating to the bathroom with assistance. The client becomes very short of breath and anxious on the way. The client begins to cry and ask for help. What is the most appropriate initial nursing​ intervention?

• Encourage the client to continue walking to the bathroom.
• Call for​ assistance, bring a​ chair, and assist the client to a sitting position.
• Quickly assist the client back to bed.
• Ask if the client would rather use a bedpan.
• Call for​ assistance, bring a​ chair, and assist the client to a sitting position.

Which ECG change indicates decreased perfusion to the myocardial muscle and possible impending​ ischemia?

• Elevated ST segment
• Depressed ST segment
• Widened QRS complex
• Absence of P waves
• Depressed ST segment

A client with impaired perfusion has finished ambulating with physical therapy. He is short of breath and fatigued. His heart rate was 60​ beats/min before physical therapy and 68​ beats/min after physical therapy. Which drug is likely the reason for the low heart​ rate?

• Analgesic agent
• Antihypertensive agent
• ​Angiotensin-converting enzyme​ (ACE) inhibitor
• Beta blocker
• Beta blocker

A client is prescribed cardiac rehabilitation and asks why it is necessary. Which response by the nurse expresses the goals of this​ program?

• ​"As you go through cardiac​ rehabilitation, you will gradually regenerate cardiac muscle tissue that will improve your heart​ function."
• ​"You have been diagnosed with congestive heart failure​ (CHF) and this program will help improve the amount of blood and oxygen

distributed to your​ muscles."

• ​"Because you have had a cardiac​ injury, this program will provide the opportunity for your heart to reach optimal​ function."
• ​"Your blood pressure is elevated and this program will help to decrease your blood pressure and reduce your risk of having a heart​ attack."
• ​"Because you have had a cardiac​ injury, this program will provide the opportunity for your heart to reach optimal​ function."

A client who has been diagnosed with new onset atrial fibrillation has been prescribed​ warfarin, an anticoagulant. Which statement of instruction should the nurse​ provide?

• ​"You should shave with an electric​ razor."
• ​"Do not take warfarin if your pulse is below​ 65."
• ​"It is recommended that you avoid eating foods high in​ protein."
• ​"Take an additional warfarin if you heart rate​ increases."
• ​"You should shave with an electric​ razor."

Which is an effective nonpharmacologic therapy for impaired perfusion in the lower​ extremities?A.Orthopedic shoes B.Ventricular assist device C.Compression stockings D.Sitting with both feet on the floor C.Compression stockings The nurse is caring for a client with congestive heart failure​ (CHF). Which medication should the nurse expect the healthcare provider to prescribe to rid the​ client's body of excess fluids and reduce​ edema?

• Beta blocker
• Calcium channel blocker
• Anticoagulant
• Diuretic
• Diuretic Terms (20)

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