ATI Perfusion || A+ Graded Already.
A nurse is performing a physical assessment of a client. Which of the following actions should
the nurse take to assess the client's tissue perfusion?
A. Perform a Romberg test
B. Check nails for Beau's lines
C. Palpate for respiratory excursion
D. Perform a blanch test correct answers D. Perform a blanch test
The blanch test is used to check for capillary refill which is an indicator for peripheral circulation
and tissue perfusion
A nurse is performing a physical assessment of a client. The nurse should recognize that which
of the following findings places the client at risk of skin integrity?
A. 3+ Achilles reflex
B. Faint pedal pulses
C. Feet warm to touch bilaterally
D. Capillary refill of <2 sec correct answers B. Faint pedal pulses
A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the
following actions should the nurse take?
A. Measure the pulse using the Doppler ultrasound stethoscope
B. Count the client's pedal pulses
C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart
D. Take the pulse at each peripheral site and count the rate for 30 sec correct answers C. Count
the apical pulse for 1 full min and describe the rhythm in the chart
A nurse is caring for a client who has difficulty breathing. The nurse should assist the client into
which of the following positions?
A. Supine
B. Lateral
C. Fowler's
D. Trendelenburg correct answers C. Fowler's
A nurse is monitoring a client who had a myocardial infarction. For which of the following
complications should the nurse monitor in the first 24 hours?
A. Infective endocarditis
B. Pericarditis
C. Ventricular dysrhythmias
D. Pulmonary emboli correct answers C. Ventricular dysrhythmias
, A nurse is caring for an older adult client who had an acute myocardial infarction (MI). When
assessing the client, the nurse should identify that older adults are prone to complications of MI
from poor tissue perfusion because of which of the following age-related factors?
A. peripheral vascular resistance increases
B. The sensitivity of blood pressure-adjusting baroreceptors increases.
C. blood is hypercoagulable and clots more quickly.
C. Cardiac medications are less effective. correct answers A. peripheral vascular resistance
increases
A nurse is caring for a client who is having a possible myocardial infarction (MI). Which of the
following findings should the nurse identify as an associated manifestation of an MI?
A. headache
B. hemoptysis
C. nausea
D. diarrhea correct answers C. nausea
A nurse is teaching a client who has coronary artery disease about the difference between angina
pectoris and myocardial infarction (MI). Which of the following manifestations should the nurse
identify as indications of MI? (Select all that apply?)
A. nausea and vomiting
B. diaphoresis and dizziness
C. chest and left arm pain that subsides with rest
D. anxiety and feelings of doom
E. bounding pulse and bradypnea correct answers A. nausea and vomiting
B. diaphoresis and dizziness
D. anxiety and feelings of doom
A nurse is planning for a client who is having a percutaneous transluminal coronary angioplasty
(PTCA) with stent placement. Which of the following actions should the nurse anticipate in the
post-procedure plan of care?
A. instruct the client about a long-term cardiac conditioning program
B. administer schedules doses of acetaminophen
C. check for peak laboratory markers of myocardial damage
D. monitor for bleeding correct answers D. monitor for bleeding
A nurse is assessing a client who is 85 years old. Which of the following findings should the
nurse identify as a manifestation of myocardial infarction?
A. sudden hemoptysis
B. acute diarrhea
C. frontal headache
D. acute confusion correct answers C. acute confusion
A nurse is performing a physical assessment of a client. Which of the following actions should
the nurse take to assess the client's tissue perfusion?
A. Perform a Romberg test
B. Check nails for Beau's lines
C. Palpate for respiratory excursion
D. Perform a blanch test correct answers D. Perform a blanch test
The blanch test is used to check for capillary refill which is an indicator for peripheral circulation
and tissue perfusion
A nurse is performing a physical assessment of a client. The nurse should recognize that which
of the following findings places the client at risk of skin integrity?
A. 3+ Achilles reflex
B. Faint pedal pulses
C. Feet warm to touch bilaterally
D. Capillary refill of <2 sec correct answers B. Faint pedal pulses
A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the
following actions should the nurse take?
A. Measure the pulse using the Doppler ultrasound stethoscope
B. Count the client's pedal pulses
C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart
D. Take the pulse at each peripheral site and count the rate for 30 sec correct answers C. Count
the apical pulse for 1 full min and describe the rhythm in the chart
A nurse is caring for a client who has difficulty breathing. The nurse should assist the client into
which of the following positions?
A. Supine
B. Lateral
C. Fowler's
D. Trendelenburg correct answers C. Fowler's
A nurse is monitoring a client who had a myocardial infarction. For which of the following
complications should the nurse monitor in the first 24 hours?
A. Infective endocarditis
B. Pericarditis
C. Ventricular dysrhythmias
D. Pulmonary emboli correct answers C. Ventricular dysrhythmias
, A nurse is caring for an older adult client who had an acute myocardial infarction (MI). When
assessing the client, the nurse should identify that older adults are prone to complications of MI
from poor tissue perfusion because of which of the following age-related factors?
A. peripheral vascular resistance increases
B. The sensitivity of blood pressure-adjusting baroreceptors increases.
C. blood is hypercoagulable and clots more quickly.
C. Cardiac medications are less effective. correct answers A. peripheral vascular resistance
increases
A nurse is caring for a client who is having a possible myocardial infarction (MI). Which of the
following findings should the nurse identify as an associated manifestation of an MI?
A. headache
B. hemoptysis
C. nausea
D. diarrhea correct answers C. nausea
A nurse is teaching a client who has coronary artery disease about the difference between angina
pectoris and myocardial infarction (MI). Which of the following manifestations should the nurse
identify as indications of MI? (Select all that apply?)
A. nausea and vomiting
B. diaphoresis and dizziness
C. chest and left arm pain that subsides with rest
D. anxiety and feelings of doom
E. bounding pulse and bradypnea correct answers A. nausea and vomiting
B. diaphoresis and dizziness
D. anxiety and feelings of doom
A nurse is planning for a client who is having a percutaneous transluminal coronary angioplasty
(PTCA) with stent placement. Which of the following actions should the nurse anticipate in the
post-procedure plan of care?
A. instruct the client about a long-term cardiac conditioning program
B. administer schedules doses of acetaminophen
C. check for peak laboratory markers of myocardial damage
D. monitor for bleeding correct answers D. monitor for bleeding
A nurse is assessing a client who is 85 years old. Which of the following findings should the
nurse identify as a manifestation of myocardial infarction?
A. sudden hemoptysis
B. acute diarrhea
C. frontal headache
D. acute confusion correct answers C. acute confusion
