OXYGENATION AND PERFUSION NUR 111

OXYGENATION AND PERFUSION NUR 111

(NCLEX QUESTIONS) questions with correct answers Which of the following assessment findings would suggest to the nurse that a Patient is at risk for alterations in perfusion?

• Blood pressure 110/68 mmHg
• Apical heart rate 80; radial beats per minute 68
• Respiratory rate 20 per minute
• Temperature 98.8°F - Answer Answer
• Apical heart rate 80; radial beats per minute 68.

• Rationale:

• The number of radial beats per minute is 12 beats slower than the apical rate of 80 per minute. This indicates weak contractions of the left ventricle and could lead to alterations in perfusion. The other assessment findings are within normal limits.

• Nursing Process: Assessment

• Cognitive Level: Analyzing

• Client Need: Physiological Integrity

A Patient is admitted with complaints of shortness of breath of 2 weeks duration.Which of the following laboratory findings would support the finding that the Patient is at risk for an alteration in perfusion?

• Increased hematocrit
• Decreased BUN
• Increased blood sugar
• Increased sedimentation rate - Answer 1. Increased hematocrit. 1 / 3

• Rationale:

• Hematocrit is the percentage of the blood that is erythrocytes, which contain the hemoglobin that carries oxygen. Long-term hypoxia may result in the body's attempt to increase oxygen-carrying capacity by increasing erythrocyte production.This can lead to an alteration in the client's perfusion. BUN is a measure of blood urea nitrogen, not oxygen-carrying capacity. Increases in blood sugar and sedimentation rate are not directly a measure of oxygenation.

• Nursing Process: Assessment

• Cognitive Level: Analyzing

• Client Need: Physiological Integrity

• Learning Outcome: 5. Outline diagnostic and laboratory tests to determine the individual's perfusion status.A Patient tells the nurse that he does not want to develop the same heart problems that his parents experienced. Which of the following should the nurse instruct this client?

• Avoid cigarette smoking
• Limit fluid intake
• Wear elastic hose
• Limit exercise to 15 minutes a day - Answer • • Answer
• Avoid cigarette smoking

Rationale:

• The one intervention that would help the client prevent the onset of cardiovascular disease would be to avoid cigarette smoking. Limiting fluids and wearing elastic hose are not known to prevent the onset of cardiovascular disease.Limiting exercise to 15 minutes a day may also not be enough exercise to prevent the onset of cardiovascular disease. 2 / 3

• Nursing Process: Implementation

• Cognitive Level: Applying

• Client Need: Health Promotion and Maintenance

• Learning Outcome: 6. Explain management of cardiovascular health and

prevention of cardiovascular illness.An elderly female patient arrives in the emergency department complaining of fatigue, nausea, vague complaint of intermittent chest discomfort, and not sleeping

well. The nurse would interpret these findings as symptoms of:

• Cardiac disease.
• Pancreatic disease.
• Normal changes of aging.
• Signs of anemia. - Answer • ANSWER
• Cardiac disease.

• Rationale:

• Many elderly women complain of vague symptoms when having a myocardial infarction including fatigue, epigastric pain, and sleep disturbances. Pancreatic disease would present pain in the abdominal region. These symptoms are not considered normal changes of aging. Anemia would present with fatigue but not with nausea or chest discomfort.

• Nursing Process: Assessment

• Cognitive Level: Analyzing

• Client Need: Physiological Integrity

• Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and caring interventions across the life span for individuals with common alterations in perfusion.

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