10/8/23, 11:59 PM Module 16 test bank
Nursing: A Concept-Based Approach to Learning Vol. 1 & 2, 3e (Pearson)
Module 16 Perfusion
The Concept of Perfusion
1) The nurse is auscultating heart sounds for a pregnant client in the third trimester of pregnancy.
The client wants to know why her doctor told her she had an extra heart sound at the last visit.
Which response by the nurse is appropriate?
A) "You will need to have an echocardiogram to determine the reason for the extra sound."
B) "You are likely experiencing heart failure due to the extra fluid that accumulates during this
time in pregnancy."
C) "You have what is known as a ventricular gallop, and it can be a normal finding during this
trimester of pregnancy."
D) "You have what is known as atrial gallop, and this is cause for concern."
Answer: C
Explanation: A) Two other heart sounds may be present in some healthy individuals. The third
heart sound (S3) may be heard in children, in young adults, or in pregnant females during the
third trimester. It is heard after S2 and is termed a ventricular gallop. When the atrioventricular
(AV) valves open, blood flow into the ventricles may cause vibrations. These vibrations create
the S3 sound during diastole. There is no need for an echocardiogram. While the S3 sound can be
associated with heart failure, this is not the case during pregnancy. S4, also known as an atrial
gallop, can also be present in healthy individuals.
B) Two other heart sounds may be present in some healthy individuals. The third heart sound
(S3) may be heard in children, in young adults, or in pregnant females during the third trimester.
It is heard after S2 and is termed a ventricular gallop. When the atrioventricular (AV) valves
open, blood flow into the ventricles may cause vibrations. These vibrations create the S3 sound
during diastole. There is no need for an echocardiogram. While the S3 sound can be associated
with heart failure, this is not the case during pregnancy. S4, also known as an atrial gallop, can
also be present in health individuals.
C) Two other heart sounds may be present in some healthy individuals. The third heart sound
(S3) may be heard in children, in young adults, or in pregnant females during the third trimester.
It is heard after S2 and is termed a ventricular gallop. When the atrioventricular (AV) valves
open, blood flow into the ventricles may cause vibrations. These vibrations create the S3 sound
during diastole. There is no need for an echocardiogram. While the S3 sound can be associated
with heart failure, this is not the case during pregnancy. S4, also known as an atrial gallop, can
also be present in health individuals.
1
Copyright © 2019 Pearson Education, Inc.
D) Two other heart sounds may be present in some healthy individuals. The third heart sound
(S3) may be heard in children, in young adults, or in pregnant females during the third trimester.
It is heard after S2 and is termed a ventricular gallop. When the atrioventricular (AV) valves
open, blood flow into the ventricles may cause vibrations. These vibrations create the S3 sound
during diastole. There is no need for an echocardiogram. While the S3 sound can be associated
with heart failure, this is not the case during pregnancy. S4, also known as an atrial gallop, can
also be present in health individuals.
Page Ref: 1134
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,10/8/23, 11:59 PM Module 16 test bank
1
Copyright © 2019 Pearson Education, Inc.
D) Two other heart sounds may be present in some healthy individuals. The third heart sound
(S3) may be heard in children, in young adults, or in pregnant females during the third trimester.
It is heard after S2 and is termed a ventricular gallop. When the atrioventricular (AV) valves
open, blood flow into the ventricles may cause vibrations. These vibrations create the S3 sound
during diastole. There is no need for an echocardiogram. While the S3 sound can be associated
with heart failure, this is not the case during pregnancy. S4, also known as an atrial gallop, can
also be present in health individuals.
Page Ref: 1134
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods
and processes. | AACN Essential Competencies: IX.7. Provide appropriate client teaching that
reflects developmental state, age, culture spirituality, client preferences, and health literacy
considerations to foster client engagement in their care. | NLN Competencies: Knowledge and
Science: Relationships between knowledge/science and quality and safe client care. | Nursing
Process: Implementation
Learning Outcome: 16.1. Analyze the physiology of perfusion in the body.
MNL LO: Analyze the concept of perfusion and its application to nursing care.
2
Copyright © 2019 Pearson Education, Inc.
2) The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate
oxygenation. What should the nurse consider when planning for this client's potential health
problem?
A) Encouraging ambulation every 30 minutes
B) Instructing on deep breathing
C) Administering medications appropriate to increase heart rate
D) Positioning to increase blood return
Answer: B
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,10/8/23, 11:59 PM Module 16 test bank
2
Copyright © 2019 Pearson Education, Inc.
2) The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate
oxygenation. What should the nurse consider when planning for this client's potential health
problem?
A) Encouraging ambulation every 30 minutes
B) Instructing on deep breathing
C) Administering medications appropriate to increase heart rate
D) Positioning to increase blood return
Answer: B
3
Copyright © 2019 Pearson Education, Inc.
Explanation: A) The client is at risk for inadequate oxygenation. The nurse should consider
teaching the client the importance of deep breathing to increase the amount of oxygen in the
body tissues. Encouraging ambulation every 30 minutes would negatively impact oxygenation.
Periods of rest should occur between activities, and no activity should be too strenuous. The
client with oxygenation issues will have tachycardia. The nurse should consider medications that
would reduce instead of increase the heart rate. The client should be in the high-Fowler position
to improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg,
which would negatively impact oxygenation.
B) The client is at risk for inadequate oxygenation The nurse should consider teaching the client
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, 10/8/23, 11:59 PM Module 16 test bank
3
Copyright © 2019 Pearson Education, Inc.
Explanation: A) The client is at risk for inadequate oxygenation. The nurse should consider
teaching the client the importance of deep breathing to increase the amount of oxygen in the
body tissues. Encouraging ambulation every 30 minutes would negatively impact oxygenation.
Periods of rest should occur between activities, and no activity should be too strenuous. The
client with oxygenation issues will have tachycardia. The nurse should consider medications that
would reduce instead of increase the heart rate. The client should be in the high-Fowler position
to improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg,
which would negatively impact oxygenation.
B) The client is at risk for inadequate oxygenation. The nurse should consider teaching the client
the importance of deep breathing to increase the amount of oxygen in the body tissues.
Encouraging ambulation every 30 minutes would negatively impact oxygenation. Periods of rest
should occur between activities, and no activity should be too strenuous. The client with
oxygenation issues will have tachycardia. The nurse should consider medications that would
reduce instead of increase the heart rate. The client should be in the high-Fowler position to
improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg, which
would negatively impact oxygenation.
C) The client is at risk for inadequate oxygenation. The nurse should consider teaching the client
the importance of deep breathing to increase the amount of oxygen in the body tissues.
Encouraging ambulation every 30 minutes would negatively impact oxygenation. Periods of rest
should occur between activities, and no activity should be too strenuous. The client with
oxygenation issues will have tachycardia. The nurse should consider medications that would
reduce instead of increase the heart rate. The client should be in the high-Fowler position to
improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg, which
would negatively impact oxygenation.
D) The client is at risk for inadequate oxygenation. The nurse should consider teaching the client
the importance of deep breathing to increase the amount of oxygen in the body tissues.
Encouraging ambulation every 30 minutes would negatively impact oxygenation. Periods of rest
should occur between activities, and no activity should be too strenuous. The client with
oxygenation issues will have tachycardia. The nurse should consider medications that would
reduce instead of increase the heart rate. The client should be in the high-Fowler position to
improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg, which
would negatively impact oxygenation.
Page Ref: 1125
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods
and processes. | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care
that reflects an understanding of human growth and development, pathophysiology,
pharmacology, medical management and nursing management across the health-illness
continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and
Science: Relationships between knowledge/science and quality and safe client care. | Nursing
Process: Planning
Learning Outcome: 16.3. Outline the relationship between perfusion and other concepts.
MNL LO: Analyze the concept of perfusion and its application to nursing care.
4
Copyright © 2019 Pearson Education, Inc.
3) An older adult client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What
would the nurse expect to be prescribed for this client?
A) Beta blocker
B) Digoxin
C) Nitrate medications
D) Fluids
Answer: A
Explanation: A) Treatment for cardiomyopathy includes calcium channel blockers, beta
blockers and antiarrhythmics Digoxin should be avoided because it increases the force of
about:blank 4/202
Nursing: A Concept-Based Approach to Learning Vol. 1 & 2, 3e (Pearson)
Module 16 Perfusion
The Concept of Perfusion
1) The nurse is auscultating heart sounds for a pregnant client in the third trimester of pregnancy.
The client wants to know why her doctor told her she had an extra heart sound at the last visit.
Which response by the nurse is appropriate?
A) "You will need to have an echocardiogram to determine the reason for the extra sound."
B) "You are likely experiencing heart failure due to the extra fluid that accumulates during this
time in pregnancy."
C) "You have what is known as a ventricular gallop, and it can be a normal finding during this
trimester of pregnancy."
D) "You have what is known as atrial gallop, and this is cause for concern."
Answer: C
Explanation: A) Two other heart sounds may be present in some healthy individuals. The third
heart sound (S3) may be heard in children, in young adults, or in pregnant females during the
third trimester. It is heard after S2 and is termed a ventricular gallop. When the atrioventricular
(AV) valves open, blood flow into the ventricles may cause vibrations. These vibrations create
the S3 sound during diastole. There is no need for an echocardiogram. While the S3 sound can be
associated with heart failure, this is not the case during pregnancy. S4, also known as an atrial
gallop, can also be present in healthy individuals.
B) Two other heart sounds may be present in some healthy individuals. The third heart sound
(S3) may be heard in children, in young adults, or in pregnant females during the third trimester.
It is heard after S2 and is termed a ventricular gallop. When the atrioventricular (AV) valves
open, blood flow into the ventricles may cause vibrations. These vibrations create the S3 sound
during diastole. There is no need for an echocardiogram. While the S3 sound can be associated
with heart failure, this is not the case during pregnancy. S4, also known as an atrial gallop, can
also be present in health individuals.
C) Two other heart sounds may be present in some healthy individuals. The third heart sound
(S3) may be heard in children, in young adults, or in pregnant females during the third trimester.
It is heard after S2 and is termed a ventricular gallop. When the atrioventricular (AV) valves
open, blood flow into the ventricles may cause vibrations. These vibrations create the S3 sound
during diastole. There is no need for an echocardiogram. While the S3 sound can be associated
with heart failure, this is not the case during pregnancy. S4, also known as an atrial gallop, can
also be present in health individuals.
1
Copyright © 2019 Pearson Education, Inc.
D) Two other heart sounds may be present in some healthy individuals. The third heart sound
(S3) may be heard in children, in young adults, or in pregnant females during the third trimester.
It is heard after S2 and is termed a ventricular gallop. When the atrioventricular (AV) valves
open, blood flow into the ventricles may cause vibrations. These vibrations create the S3 sound
during diastole. There is no need for an echocardiogram. While the S3 sound can be associated
with heart failure, this is not the case during pregnancy. S4, also known as an atrial gallop, can
also be present in health individuals.
Page Ref: 1134
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,10/8/23, 11:59 PM Module 16 test bank
1
Copyright © 2019 Pearson Education, Inc.
D) Two other heart sounds may be present in some healthy individuals. The third heart sound
(S3) may be heard in children, in young adults, or in pregnant females during the third trimester.
It is heard after S2 and is termed a ventricular gallop. When the atrioventricular (AV) valves
open, blood flow into the ventricles may cause vibrations. These vibrations create the S3 sound
during diastole. There is no need for an echocardiogram. While the S3 sound can be associated
with heart failure, this is not the case during pregnancy. S4, also known as an atrial gallop, can
also be present in health individuals.
Page Ref: 1134
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods
and processes. | AACN Essential Competencies: IX.7. Provide appropriate client teaching that
reflects developmental state, age, culture spirituality, client preferences, and health literacy
considerations to foster client engagement in their care. | NLN Competencies: Knowledge and
Science: Relationships between knowledge/science and quality and safe client care. | Nursing
Process: Implementation
Learning Outcome: 16.1. Analyze the physiology of perfusion in the body.
MNL LO: Analyze the concept of perfusion and its application to nursing care.
2
Copyright © 2019 Pearson Education, Inc.
2) The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate
oxygenation. What should the nurse consider when planning for this client's potential health
problem?
A) Encouraging ambulation every 30 minutes
B) Instructing on deep breathing
C) Administering medications appropriate to increase heart rate
D) Positioning to increase blood return
Answer: B
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,10/8/23, 11:59 PM Module 16 test bank
2
Copyright © 2019 Pearson Education, Inc.
2) The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate
oxygenation. What should the nurse consider when planning for this client's potential health
problem?
A) Encouraging ambulation every 30 minutes
B) Instructing on deep breathing
C) Administering medications appropriate to increase heart rate
D) Positioning to increase blood return
Answer: B
3
Copyright © 2019 Pearson Education, Inc.
Explanation: A) The client is at risk for inadequate oxygenation. The nurse should consider
teaching the client the importance of deep breathing to increase the amount of oxygen in the
body tissues. Encouraging ambulation every 30 minutes would negatively impact oxygenation.
Periods of rest should occur between activities, and no activity should be too strenuous. The
client with oxygenation issues will have tachycardia. The nurse should consider medications that
would reduce instead of increase the heart rate. The client should be in the high-Fowler position
to improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg,
which would negatively impact oxygenation.
B) The client is at risk for inadequate oxygenation The nurse should consider teaching the client
about:blank 3/202
, 10/8/23, 11:59 PM Module 16 test bank
3
Copyright © 2019 Pearson Education, Inc.
Explanation: A) The client is at risk for inadequate oxygenation. The nurse should consider
teaching the client the importance of deep breathing to increase the amount of oxygen in the
body tissues. Encouraging ambulation every 30 minutes would negatively impact oxygenation.
Periods of rest should occur between activities, and no activity should be too strenuous. The
client with oxygenation issues will have tachycardia. The nurse should consider medications that
would reduce instead of increase the heart rate. The client should be in the high-Fowler position
to improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg,
which would negatively impact oxygenation.
B) The client is at risk for inadequate oxygenation. The nurse should consider teaching the client
the importance of deep breathing to increase the amount of oxygen in the body tissues.
Encouraging ambulation every 30 minutes would negatively impact oxygenation. Periods of rest
should occur between activities, and no activity should be too strenuous. The client with
oxygenation issues will have tachycardia. The nurse should consider medications that would
reduce instead of increase the heart rate. The client should be in the high-Fowler position to
improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg, which
would negatively impact oxygenation.
C) The client is at risk for inadequate oxygenation. The nurse should consider teaching the client
the importance of deep breathing to increase the amount of oxygen in the body tissues.
Encouraging ambulation every 30 minutes would negatively impact oxygenation. Periods of rest
should occur between activities, and no activity should be too strenuous. The client with
oxygenation issues will have tachycardia. The nurse should consider medications that would
reduce instead of increase the heart rate. The client should be in the high-Fowler position to
improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg, which
would negatively impact oxygenation.
D) The client is at risk for inadequate oxygenation. The nurse should consider teaching the client
the importance of deep breathing to increase the amount of oxygen in the body tissues.
Encouraging ambulation every 30 minutes would negatively impact oxygenation. Periods of rest
should occur between activities, and no activity should be too strenuous. The client with
oxygenation issues will have tachycardia. The nurse should consider medications that would
reduce instead of increase the heart rate. The client should be in the high-Fowler position to
improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg, which
would negatively impact oxygenation.
Page Ref: 1125
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods
and processes. | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care
that reflects an understanding of human growth and development, pathophysiology,
pharmacology, medical management and nursing management across the health-illness
continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and
Science: Relationships between knowledge/science and quality and safe client care. | Nursing
Process: Planning
Learning Outcome: 16.3. Outline the relationship between perfusion and other concepts.
MNL LO: Analyze the concept of perfusion and its application to nursing care.
4
Copyright © 2019 Pearson Education, Inc.
3) An older adult client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What
would the nurse expect to be prescribed for this client?
A) Beta blocker
B) Digoxin
C) Nitrate medications
D) Fluids
Answer: A
Explanation: A) Treatment for cardiomyopathy includes calcium channel blockers, beta
blockers and antiarrhythmics Digoxin should be avoided because it increases the force of
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