Perfusion Practice NCLEX Questions

Perfusion Practice NCLEX Questions Leave the first rating Students also studied Terms in this set (8) Science MedicineNursing Save Perfusion NCLEX Questions 23 terms TiffanyNewkirk5 Preview Perfusion Practice Questions 116 terms SharonEngland Preview Milestones NCLEX questions 44 terms trburk514Preview Renal C 35 terms spu Client admitted with acute exacerbation of HF, which clinical manifestations would the nurse expect to fid when assessing?

• Apical pulse rate of 110 and 4+ pitting edema of feet
• Apical pulse rate of 110 and 4+ pitting edema of feet

The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing dx of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short term goal would be best for the client?

• be able to ambulate in the hall by date of discharge
• have an audible S1 and S2 with no S3 heard by end of

shift

• Turn, cough, and deep breathe every two hours
• Have a pulse ox reading of 98% by day two of care
• Have an audible S1 and S2 with no S3 heard by end of shift

The nurse enters the room of the client dx with HF. The client is lying in bed experiencing SOB and is cool and clammy. Which intervention would the nurse implement first?

• sponge the client's forehead
• obtain a pulse ox reading
• take the client's VS
• assist the client into a sitting position
• Assist the client into a sitting position (raise HOB)

The nurse is assessing the client dx with HF. Which S/S would indicate that medical treatment has been effective?

• peripheral pitting edema has gone from 3+ to 4+
• able to take the radial pulse accurately
• able to perform ADLs w/out dyspnea
• Minimal JVD
• Able to perform ADLs w/out dyspnea

The nurse is assessing the client dx with HF. Which laboratory data would indicate the client is experiencing HF?

• Elevated BNP
• Elevated creatine kinase
• Positive D-dimer
• Positive ventilation/perfusion scan
• Elevated BNP

The nurse on the telemetry unit has just received the AM shift report. Which client should the nurse assess first?

• The client dx w/ MI who has an audible S3 heart sound
• The client dx w/ HF who has 4+ sacral pitting edema
• The client dx w/ pneumonia who has a pulse ox reading

of 94%

• The client w/ chronic renal failure who has an elevated

creatinine level

• The client dx w/ MI who has an audible S3 heart sound

A nurse has taken a health hx of a client, and IDs that which factors could contribute to the client's hyperlipidemia?

• Dietary saturated fats are restricted
• Intake of dietary fiber is minimal
• The client drinks a glass of wine once or twice a week
• The client is 30 lb overweight
• The client smokes cigarettes
• Intake of dietary fiber is minimal
• The client is 30 lb overweight
• The client smokes cigarettes

Which nursing dx would the nurse identify as the priority for a client dx with hyperlipidemia?

• Altered nutrition related to dietary knowledge deficit
• risk for cardiac complications
• risk for infection secondary to invasive procedures
• Risk for injury related to cardiovascular complications
• Altered nutrition related to dietary knowledge deficit

(Only option that is an actual problem; not just at risk)