OXYGENATION AND PERFUSION NUR 111 (NCLEX QUESTIONS) WITH COMPLETE SOLUTIONS|100% PASS

Which of the following assessment findings would suggest to the nurse that a Patient is at risk for alterations in perfusion? 1. Blood pressure 110/68 mmHg 2. Apical heart rate 80; radial beats per minute 68 3. Respiratory rate 20 per minute 4. Temperature 98.8°F Answer 2. 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? 1. Increased hematocrit 2. Decreased BUN 3. Increased blood sugar 4. Increased sedimentation rate 1. Increased hematocrit. • 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. 00:01 01:36 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? 1. Avoid cigarette smoking 2. Limit fluid intake 3. Wear elastic hose 4. Limit exercise to 15 minutes a day • • Answer 1. 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. • 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: 1. Cardiac disease. 2. Pancreatic disease. 3. Normal changes of aging. 4. Signs of anemia. • ANSWER 1. 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. Which of the following interventions would be appropriate for a Patient with the nursing diagnosis of excess fluid volume? 1. Assess respiratory status and lung sounds every 4 hours and prn 2. Provide oxygen as prescribed 3. Monitor brain natriuretic peptide (BNP) level 4. Provide information about activity upon discharge • ANSWER 1. Assess respiratory status and lung sounds every 4 hours and prn • Rationale: • Interventions appropriate for the nursing diagnosis of excess fluid volume include assessing respiratory status and lung sounds every 4 hours and prn. Providing oxygen and monitoring BNP level are intervention appropriate for the diagnosis of decreased cardiac output. Providing information about activity upon discharge would be appropriate for the nursing diagnosis of activity intolerance. • Nursing Process: Planning • Cognitive Level: Applying • Client Need: Physiological Integrity • Learning Outcome: 5. Create a plan of care for individuals with cardiomyopathy and their family members. • The nurse would suspect deep venous thrombosis in a Patient with which of the following assessment findings? 1. Bilateral calf tenderness after walking up a flight of stairs 2. Swelling in one leg with pitting edema 3. Shortness of breath after activity 4. Two plus palpable pedal pulses • ANSWER 2. Swelling in one leg with pitting edema • Rationale: • Swelling in one leg with pitting edema is suggestive of deep venous thrombosis in the vein of the affected leg because the clot is obstructing the venous return from the leg. Bilateral calf tenderness may be a normal reaction to the exercise of climbing stairs. Shortness of breath that subsides after activity and two plus palpable pulses are normal. • Nursing Process: Assessment • Cognitive Level: Analyzing • Client Need: Physiological Integrity • Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of deep venous thrombosis. Which of the following Patients does the nurse identify as having the greatest risk for deep venous thrombosis? 1. The Patient admitted with new-onset type II diabetes mellitus 2. The Patient admitted with community-acquired pneumonia 3. The postoperative Patient following knee replacement surgery 4. The postoperative Patient following laparoscopic gallbladder surgery • ANSWER 3. The postoperative client following knee replacement surgery. • Rationale: • The postoperative client following knee replacement surgery is correct because deep venous thrombosis develops in more than 50% of clients having orthopedic surgery related to the nature of the surgery itself as well as the prolonged immobility occurring after surgery. The client admitted with new-onset type II diabetes mellitus, the client admitted with community-acquired pneumonia, and the postoperative client following laparoscopic gallbladder surgery would not be lower risk for deep venous thrombosis because none of these clients has prolonged immobility. • Nursing Process: Assessment • Cognitive Level: Analyzing • Client Need: Physiological Integrity • Learning Outcome: 2. Identify risk factors associated with deep venous thrombosis • NCLEX QUESTION A postpartum patient recovering from a deep vein thrombosis is being discharged. About which of the following topics should the nurse instruct this client? (Select all that apply.) 1. Avoid crossing the legs 2. Avoid prolonged standing or sitting 3. Take frequent walks 4. Take a daily aspirin dose of 650 mg 5. Avoid long car trips • ANSWER 1. Avoid crossing the legs 2. Avoid prolonged standing or sitting 3. Take frequent walks. • Rationale: • The client should be instructed to avoid crossing the legs because it increases pressure on the veins of the lower extremities. The client should be instructed also to avoid prolonged standing or sitting, which contributes to venous stasis. The client should also be instructed to take frequent walks to promote venous return. The client should not be instructed to take a daily aspirin because it will increase anticoagulant activity and could interact with other medication prescribed for the treatment of the deep vein thrombosis. The client does not need to be instructed to avoid long car trips but rather to take frequent breaks during long car trips. • Nursing Process: Implementation • Cognitive Level: Applying • Client Need: Physiological Integrity • Learning Outcome: 5. Create a plan of care for individuals with deep venous thrombosis and their families. A Patient diagnosed with a deep vein thrombosis is receiving intravenous heparin. The nurse would identify which of the following as being the priority outcome for this Patient? 1. The Patient will not disturb the intravenous infusion. 2. The Patient will not experience bleeding. 3. The Patient will comply with dietary restrictions. 4. The Patient will keep the right leg elevated on two pillows. • ANSWER 2. The Patient will not experience bleeding. • Rationale: • An absence of bleeding is a priority outcome for any client receiving anticoagulant therapy. Disturbing the intravenous line could relate to bleeding, but this does not directly correlate with heparin. Dietary restrictions are important but not as high a priority as an absence of bleeding. Elevation of the affected extremity is important but not as high a priority as an absence of bleeding. • Nursing Process: Planning • Cognitive Level: Analyzing A patient is admitted with a possible deep vein thrombosis. Nursing interventions should be implemented to prevent which complication? 1. Myocardial infarction 2. Renal failure 3. Pulmonary embolism 4. Pneumonia ANSWER 3. Pulmonary embolism. • Rationale: • The presence of a deep vein thrombosis is a risk factor for the development of a pulmonary embolism. The nurse should design interventions to help prevent that development. There is less likelihood that the thrombosis would cause myocardial infarction, renal failure, or pneumonia. • Nursing Process: Implementation • Cognitive Level: Analyzing • Client Need: Physiological Integrity • Learning Outcome: 8. Employ evidence-based caring interventions for an individual with deep venous thrombosis. • During hospitalization for congestive heart failure, a patient awakens during the night frightened and short of breath. This client most likely is experiencing: 1. Multisystem heart failure. 2. Cardiomyopathy. 3. Paroxysmal nocturnal dyspnea. 4. High-output failure. ANSWER 3. Paroxysmal nocturnal dyspnea. • Rationale: • Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night. This causes fluid overload and pulmonary congestion. The client awakens at night short of breath and frightened. The client is not experiencing multisystem heart failure, cardiomyopathy, or high-output failure. • Nursing Process: Assessment • Cognitive Level: Analyzing • Client Need: Physiological Integrity • Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of heart failure