NCLEX style questions: Perfusion with 100% correct answers

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? A. Dehydration from loss of fluids B. The​ client's age C. Stress from being sick D. Effects of medications the client has taken A. 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? A. ​"Take blood pressure at different times every day to be sure it is not elevated at different times of the​ day." B. ​"Blood pressure should be taken before getting up in the​ morning, with the arm elevated over the level of the​ heart." C. ​"Rest for at least 5 minutes before taking blood pressure and at least 30 minutes after drinking caffeinated​ beverages." D. ​"Blood pressure readings will be erroneously high if the arm is above the level of the​ heart." C. ​"Rest for at least 5 minutes before taking blood pressure and at least 30 minutes after drinking caffeinated​ beverages." 00:00 01:36 A​ 45-year-old client has been diagnosed with hypertension. Which modifiable risk factor would the nurse​ assess? A. Family History B. Age C. Stress D. Sex C. 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.) A. Lethargy B. Increased pulse rate C. Capillary refill less than <3 seconds D. Decreased urine output E. Palpable pedal pulses A. Lethargy B. Increased pulse rate D. 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? A. Have the client rest quietly for 5 minutes and retake the blood pressure. B. Ask the client to tell you her usual blood pressure. C. Document the blood pressure and tell the physician the client is anxious. D. Instruct the client to calm down so accurate vital signs can be obtained. A. 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? A. Have the client lie still for 5 minutes and attempt another measurement. B. Obtain an apical pulse for 1 minute. C. Document the best estimation of the pulse. D. Ask another nurse to attempt a radial pulse measurement. B. 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? A. Eat a diet with a minimum of​ 20% fat. B. Take statin medications as prescribed. C. Exercise for 30 minutes 3 times a week. D. Cut smoking by half the usual amount. C. 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? A. Sleeping with more pillows or in a recliner B. Nocturnal leg cramping C. Reporting the need for a​ mid-afternoon nap D. Decreased appetite A. 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? A. At the left nipple at the 4th intercostal space B. At the right nipple just above the 3rd intercostal space C. Just below the clavicle between the 1st and 2nd intercostal space D. In the left​ mid-axillary area at the 4th intercostal space A. At the left nipple at the 4th intercostal space