Test Bank - Clinical Reasoning Cases in Nursing 10th Edition (Harding,
2024\25), All Chapters 1-72 ANSWERSHEET
Chapter 1.Perfusion
MULTIPLE CHOICE
1. The nurse is explaining to a student nurse about impaired central
perfusion. The nurse knows the student understands this problem when
the student states, Central perfusion
a. is monitored only by the physician.
b. involves the entire body.
c. is decreased with hypertension.
d. is toxic to the cardiac system.
ANS: B
Central perfusion does involve the entire body as all organs are
supplied with oxygen and vital nutrients. The physician does not control
the bodys ability for perfusion. Central perfusion is not decreased with
hypertension. Central perfusion is not toxic to the cardiac system.
2. A patient was diagnosed with hypertension. The patient asks the
nurse how this disease could have happened to them. The nurses best
response is Hypertension
a. happens to everyone sooner or later. Dont be concerned about
it.
b. can happen from eating a poor diet, so change what you are
eating.
, c. can happen from arterial changes that impede the blood flow.
d. happens when people do not exercise, so you should walk every
day.
ANS: C
Hardening of the arteries from atherosclerosis can cause hypertension
in the patient.
Hypertension does not happen to everyone. Changing the patients diet
and exercising may be a positive life change, but these answers do not
explain to the patient how the disease could have happened.
3. The patient asks the nurse to explain the sinoatrial node in the
heart. The nurses best response would be, The sinoatrial node
a. provides the heart with the stimulation to beat in a normal
rhythm.
b. protects the heart from atherosclerotic changes.
c. provides the heart with oxygenated blood.
d. protects the heart from infection.
ANS: A
The sinoatrial node is the natural pacemaker of the heart, and it
assists the heart to beat in a
normal rhythm. The sinoatrial node does not protect from
atherosclerotic changes or infection, and it does not directly provide
the heart with oxygenated blood.
4. The patient is brought to the emergency department after a motor
vehicle accident. The patient is diagnosed with internal bleeding. The
nurses primary concern is to monitor for
a. mental alertness.
b. perfusion.
,Test Bank - Clinical Reasoning Cases in Nursing 10th Edition (Harding,
2024\25), All Chapters 1-72 ANSWERSHEET
c. pain.
d. reaction to medications.
ANS: B
Perfusion is the correct answer, because with internal bleeding, the
nurse should monitor vital signs to be sure perfusion is happening.
Mental alertness, pain, and medication reactions are important but not
the primary concern.
5. A patients serum electrolytes are being monitored. The nurse
notices that the potassium level is low. The nurse knows that the
patient should be observed for
a. tissue ischemia.
b. brain malformations.
c. intestinal blockage.
d. cardiac dysthymia.
ANS: D
Cardiac dysthymia is a possibility when serum potassium is high or low.
Tissue ischemia, brain malformations, or intestinal blockage do not
have a direct correlation to potassium irregularities. 6. A nurse is
explaining to a student nurse about perfusion. The nurse knows the
student understands the concept of perfusion when the student states,
Perfusion
a. is a normal function of the body, and I dont have to be concerned
about it.
b. is monitored by the physician, and I just follow orders.
c. is monitored by vital signs and capillary refill.
, d. varies as a person ages, so I would expect changes in the body.
ANS: C
The best method to monitor perfusion is to monitor vital signs and
capillary refill. This allows the nurse to know if perfusion is adequate
to maintain vital organs. The nurse does have to be concerned about
perfusion. Perfusion is not only monitored by the physician but the nurse
too.
Perfusion does not always change as the person ages.
7. The nurse is conducting a patient assessment. The patient tells the
nurse that he has smoked two packs of cigarettes per day for 27 years.
The nurse may find which data upon assessment?
a. Blood pressure above the normal range
b. Bounding pedal pulses
c. Night blindness
d. Reflux disease
ANS: A
Smokers have a constriction of the blood vessels due to the tar and
nicotine in cigarettes. This constriction may lead to hypertension.
Bounding pulses, night blindness, and reflux disease do not have a direct
link to smoking.
Chapter 2.Gas Exchange
MULTIPLE CHOICE
1. The nurse is assigned a group of patients. Which patient would the
nurse identify as being at increased risk for impaired gas exchange? A
patient
a. with a blood glucose of 350 mg/dL
,Test Bank - Clinical Reasoning Cases in Nursing 10th Edition (Harding,
2024\25), All Chapters 1-72 ANSWERSHEET
b. who has been on anticoagulants for 10 days
c. with a hemoglobin of 8.5 g/dL
d. with a heart rate of 100 beats/min and blood pressure of 100/60
ANS: C
The hemoglobin is low (anemia), therefore the ability of the blood to
carry oxygen is decreased.
High blood glucose and/or anticoagulants do not alter the oxygen
carrying capacity of the blood. A heart rate of 100 beats/min and blood
pressure of 100/60 are not indicative of oxygen carrying capacity of
the blood.
2. The nurse is reviewing the patients arterial blood gas results. The
PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What
would the nurse expect to observe on assessment of this patient?
a. Disorientation and tremors
b. Tachycardia and decreased blood pressure
c. Increased anxiety and irritability
d. Hyperventilation and lethargy
ANS: A
The patient is experiencing respiratory acidosis ( pH, and PaCO2 ) which
may be manifested by disorientation, tremors, possible seizures, and
decreased level of consciousness. Tachycardia and decreased blood
pressure are not characteristic of a problem of respiratory acidosis.
Increased anxiety and hyperventilation will cause respiratory
alkalosis, which is manifested by an increase in pH and a decrease in
PaCO2.
3. The nurse would identify which patient as having a problem of
impaired gas exchange secondary to a perfusion problem? A patient
with
, a. peripheral arterial disease of the lower extremities
b. chronic obstructive pulmonary disease (COPD)
c. chronic asthma
d. severe anemia secondary to chemotherapy
ANS: A
Perfusion relates to the ability of the blood to deliver oxygen to the
cellular level and return the carbon dioxide to the lung for removal.
COPD and asthma are examples of a ventilation problem. Severe anemia
is an example of a transport problem of gas exchange.
4. The nurse is assessing a patients differential white blood cell
count. What implications would this test have on evaluating the
adequacy of a patients gas exchange?
a. An elevation of the total white cell count indicates
generalized inflammation.
b. Eosinophil count will assist to identify the presence of a
respiratory infection.
c. White cell count will differentiate types of respiratory
bacteria.
d. Level of neutrophils provides guidelines to monitor a chronic
infection.
ANS: A
Elevation of total white cell count is indicative of inflammation that is
often due to an infection.
Upper respiratory infections are common problems in altering a
patients gas exchange.
,Test Bank - Clinical Reasoning Cases in Nursing 10th Edition (Harding,
2024\25), All Chapters 1-72 ANSWERSHEET
Eosinophil cells are increased in an allergic response. Neutrophils are
more indicative of an acute inflammatory response. White cells do not
assist to differentiate types of respiratory bacteria.
Monocytes are an indicator of progress of a chronic infection.
5. The acid-base status of a patient is dependent on normal gas
exchange. Which patient would the nurse identify as having an increased
risk for the development of respiratory acidosis? A patient with
a. chronic lung disease with increased carbon dioxide retention
b. acute anxiety, hyperventilation, and decreased carbon dioxide
retention
c. decreased cardiac output with increased serum lactic acid
production
d. gastric drainage with increased removal of gastric acid
ANS: A
Respiratory acidosis is caused by an increase in retention of carbon
dioxide, regardless of the underlying disease. A decrease in carbon
dioxide retention may lead to respiratory alkalosis. An increase in
production of lactic acid leads to metabolic acidosis. Removal of an
acid (gastric secretions) will lead to a metabolic alkalosis.
6. Which patient would the nurse identify as being at an increased risk
for altered transport of oxygen? A patient with
a. hemoglobin level of 8.0
b. bronchoconstriction and mucus
c. peripheral arterial disease
d. decreased thoracic expansion
ANS: A
,Altered transportation of oxygen refers to patients with insufficient
red blood cells to transport the oxygen present. Bronchoconstriction
and decreased thoracic expansion (spinal cord injury) would result in
impairment of ventilation. Peripheral vascular disease would result in
inadequate perfusion.
7. A 3-month-old infant is at increased risk for developing anemia. The
nurse would identify which principle contributing to this risk?
a. The infant is becoming more active.
b. There is an increase in intake of breast milk or formula.
c. The infant is unable to maintain an adequate iron intake.
d. A depletion of fetal hemoglobin occurs.
ANS: D
Fetal hemoglobin is present for about 5 months. The fetal hemoglobin
begins deteriorating, and around 2 to 3 months the infant is at
increased risk of developing an anemia due to decreasing levels of
hemoglobin. Breast milk or formula is the primary food intake up to
around 6 months. Often iron supplemented formula is offered, and/or an
iron supplement is given if the infant is breastfed.
REF: 162 OBJ: NCLEX Client Needs Category: Health Promotion and
Maintenance
8. Which clinical management prevention concept would the nurse
identify as representative of secondary prevention?
a. Decreasing venous stasis and risk for pulmonary emboli
b. Implementation of strict hand washing routines
c. Maintaining current vaccination schedules
d. Prevention of pneumonia in patients with chronic lung disease
,Test Bank - Clinical Reasoning Cases in Nursing 10th Edition (Harding,
2024\25), All Chapters 1-72 ANSWERSHEET
ANS: D
Prevention of and treatment of existing health problems to avoid
further complications is an example of secondary prevention. Primary
prevention includes infection control (hand washing), smoking cessation,
immunizations, and prevention of postoperative complications.
MULTIPLE RESPONSE
1. The nurse would identify which body systems as directly involved in
the process of normal gas exchange? (Select all that apply.)
a. Neurologic system
b. Endocrine system
c. Pulmonary system
d. Immune system
e. Cardiovascular system
f. Hepatic system
ANS: A, C, E
The neurologic system controls respiratory drive; the respiratory
system controls delivery of oxygen to the lung capillaries; and the
cardiac system is responsible for the perfusion of vital organs. These
systems are primarily responsible for the adequacy of gas exchange in
the body. The endocrine and hepatic systems are not directly involved
with gas exchange. The immune system primarily protects the body
against infection.
2. The nurse is assessing a patient for the adequacy of ventilation.
What assessment findings would indicate the patient has good
ventilation? (Select all that apply.)
a. Respiratory rate is 24 breaths/min.
, b. Oxygen saturation level is 98%.
c. The right side of the thorax expands slightly more than the
left.
d. Trachea is just to the left of the sternal notch.
e. Nail beds are pink with good capillary refill.
f. There is presence of quiet, effortless breath sounds at lung
base bilaterally.
ANS: B, E, F
Oxygen saturation level should be between 95 and 100%; nail beds
should be pink with capillary refill of about 3 seconds; and breath
sounds should be present at base of both lungs. Normal respiratory
rate is between 12 and 20 breaths/min. The trachea should be in midline
with the sternal notch. The thorax should expand equally on both sides.
Chapter 3.Mobility
MULTIPLE CHOICE
1. A patient who has been in the hospital for several weeks is about to
be discharged. The patient is weak from the hospitalization and asks
the nurse to explain why this is happening. The nurses best response is
You are weak because
a. your iron level is low. This is known as anemia.
b. of your immobility in the hospital. This is known as
deconditioning.
c. of your poor appetite. This is known as malnutrition.
d. of your medications. This is known as drug induced weakness.
ANS: B
2024\25), All Chapters 1-72 ANSWERSHEET
Chapter 1.Perfusion
MULTIPLE CHOICE
1. The nurse is explaining to a student nurse about impaired central
perfusion. The nurse knows the student understands this problem when
the student states, Central perfusion
a. is monitored only by the physician.
b. involves the entire body.
c. is decreased with hypertension.
d. is toxic to the cardiac system.
ANS: B
Central perfusion does involve the entire body as all organs are
supplied with oxygen and vital nutrients. The physician does not control
the bodys ability for perfusion. Central perfusion is not decreased with
hypertension. Central perfusion is not toxic to the cardiac system.
2. A patient was diagnosed with hypertension. The patient asks the
nurse how this disease could have happened to them. The nurses best
response is Hypertension
a. happens to everyone sooner or later. Dont be concerned about
it.
b. can happen from eating a poor diet, so change what you are
eating.
, c. can happen from arterial changes that impede the blood flow.
d. happens when people do not exercise, so you should walk every
day.
ANS: C
Hardening of the arteries from atherosclerosis can cause hypertension
in the patient.
Hypertension does not happen to everyone. Changing the patients diet
and exercising may be a positive life change, but these answers do not
explain to the patient how the disease could have happened.
3. The patient asks the nurse to explain the sinoatrial node in the
heart. The nurses best response would be, The sinoatrial node
a. provides the heart with the stimulation to beat in a normal
rhythm.
b. protects the heart from atherosclerotic changes.
c. provides the heart with oxygenated blood.
d. protects the heart from infection.
ANS: A
The sinoatrial node is the natural pacemaker of the heart, and it
assists the heart to beat in a
normal rhythm. The sinoatrial node does not protect from
atherosclerotic changes or infection, and it does not directly provide
the heart with oxygenated blood.
4. The patient is brought to the emergency department after a motor
vehicle accident. The patient is diagnosed with internal bleeding. The
nurses primary concern is to monitor for
a. mental alertness.
b. perfusion.
,Test Bank - Clinical Reasoning Cases in Nursing 10th Edition (Harding,
2024\25), All Chapters 1-72 ANSWERSHEET
c. pain.
d. reaction to medications.
ANS: B
Perfusion is the correct answer, because with internal bleeding, the
nurse should monitor vital signs to be sure perfusion is happening.
Mental alertness, pain, and medication reactions are important but not
the primary concern.
5. A patients serum electrolytes are being monitored. The nurse
notices that the potassium level is low. The nurse knows that the
patient should be observed for
a. tissue ischemia.
b. brain malformations.
c. intestinal blockage.
d. cardiac dysthymia.
ANS: D
Cardiac dysthymia is a possibility when serum potassium is high or low.
Tissue ischemia, brain malformations, or intestinal blockage do not
have a direct correlation to potassium irregularities. 6. A nurse is
explaining to a student nurse about perfusion. The nurse knows the
student understands the concept of perfusion when the student states,
Perfusion
a. is a normal function of the body, and I dont have to be concerned
about it.
b. is monitored by the physician, and I just follow orders.
c. is monitored by vital signs and capillary refill.
, d. varies as a person ages, so I would expect changes in the body.
ANS: C
The best method to monitor perfusion is to monitor vital signs and
capillary refill. This allows the nurse to know if perfusion is adequate
to maintain vital organs. The nurse does have to be concerned about
perfusion. Perfusion is not only monitored by the physician but the nurse
too.
Perfusion does not always change as the person ages.
7. The nurse is conducting a patient assessment. The patient tells the
nurse that he has smoked two packs of cigarettes per day for 27 years.
The nurse may find which data upon assessment?
a. Blood pressure above the normal range
b. Bounding pedal pulses
c. Night blindness
d. Reflux disease
ANS: A
Smokers have a constriction of the blood vessels due to the tar and
nicotine in cigarettes. This constriction may lead to hypertension.
Bounding pulses, night blindness, and reflux disease do not have a direct
link to smoking.
Chapter 2.Gas Exchange
MULTIPLE CHOICE
1. The nurse is assigned a group of patients. Which patient would the
nurse identify as being at increased risk for impaired gas exchange? A
patient
a. with a blood glucose of 350 mg/dL
,Test Bank - Clinical Reasoning Cases in Nursing 10th Edition (Harding,
2024\25), All Chapters 1-72 ANSWERSHEET
b. who has been on anticoagulants for 10 days
c. with a hemoglobin of 8.5 g/dL
d. with a heart rate of 100 beats/min and blood pressure of 100/60
ANS: C
The hemoglobin is low (anemia), therefore the ability of the blood to
carry oxygen is decreased.
High blood glucose and/or anticoagulants do not alter the oxygen
carrying capacity of the blood. A heart rate of 100 beats/min and blood
pressure of 100/60 are not indicative of oxygen carrying capacity of
the blood.
2. The nurse is reviewing the patients arterial blood gas results. The
PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What
would the nurse expect to observe on assessment of this patient?
a. Disorientation and tremors
b. Tachycardia and decreased blood pressure
c. Increased anxiety and irritability
d. Hyperventilation and lethargy
ANS: A
The patient is experiencing respiratory acidosis ( pH, and PaCO2 ) which
may be manifested by disorientation, tremors, possible seizures, and
decreased level of consciousness. Tachycardia and decreased blood
pressure are not characteristic of a problem of respiratory acidosis.
Increased anxiety and hyperventilation will cause respiratory
alkalosis, which is manifested by an increase in pH and a decrease in
PaCO2.
3. The nurse would identify which patient as having a problem of
impaired gas exchange secondary to a perfusion problem? A patient
with
, a. peripheral arterial disease of the lower extremities
b. chronic obstructive pulmonary disease (COPD)
c. chronic asthma
d. severe anemia secondary to chemotherapy
ANS: A
Perfusion relates to the ability of the blood to deliver oxygen to the
cellular level and return the carbon dioxide to the lung for removal.
COPD and asthma are examples of a ventilation problem. Severe anemia
is an example of a transport problem of gas exchange.
4. The nurse is assessing a patients differential white blood cell
count. What implications would this test have on evaluating the
adequacy of a patients gas exchange?
a. An elevation of the total white cell count indicates
generalized inflammation.
b. Eosinophil count will assist to identify the presence of a
respiratory infection.
c. White cell count will differentiate types of respiratory
bacteria.
d. Level of neutrophils provides guidelines to monitor a chronic
infection.
ANS: A
Elevation of total white cell count is indicative of inflammation that is
often due to an infection.
Upper respiratory infections are common problems in altering a
patients gas exchange.
,Test Bank - Clinical Reasoning Cases in Nursing 10th Edition (Harding,
2024\25), All Chapters 1-72 ANSWERSHEET
Eosinophil cells are increased in an allergic response. Neutrophils are
more indicative of an acute inflammatory response. White cells do not
assist to differentiate types of respiratory bacteria.
Monocytes are an indicator of progress of a chronic infection.
5. The acid-base status of a patient is dependent on normal gas
exchange. Which patient would the nurse identify as having an increased
risk for the development of respiratory acidosis? A patient with
a. chronic lung disease with increased carbon dioxide retention
b. acute anxiety, hyperventilation, and decreased carbon dioxide
retention
c. decreased cardiac output with increased serum lactic acid
production
d. gastric drainage with increased removal of gastric acid
ANS: A
Respiratory acidosis is caused by an increase in retention of carbon
dioxide, regardless of the underlying disease. A decrease in carbon
dioxide retention may lead to respiratory alkalosis. An increase in
production of lactic acid leads to metabolic acidosis. Removal of an
acid (gastric secretions) will lead to a metabolic alkalosis.
6. Which patient would the nurse identify as being at an increased risk
for altered transport of oxygen? A patient with
a. hemoglobin level of 8.0
b. bronchoconstriction and mucus
c. peripheral arterial disease
d. decreased thoracic expansion
ANS: A
,Altered transportation of oxygen refers to patients with insufficient
red blood cells to transport the oxygen present. Bronchoconstriction
and decreased thoracic expansion (spinal cord injury) would result in
impairment of ventilation. Peripheral vascular disease would result in
inadequate perfusion.
7. A 3-month-old infant is at increased risk for developing anemia. The
nurse would identify which principle contributing to this risk?
a. The infant is becoming more active.
b. There is an increase in intake of breast milk or formula.
c. The infant is unable to maintain an adequate iron intake.
d. A depletion of fetal hemoglobin occurs.
ANS: D
Fetal hemoglobin is present for about 5 months. The fetal hemoglobin
begins deteriorating, and around 2 to 3 months the infant is at
increased risk of developing an anemia due to decreasing levels of
hemoglobin. Breast milk or formula is the primary food intake up to
around 6 months. Often iron supplemented formula is offered, and/or an
iron supplement is given if the infant is breastfed.
REF: 162 OBJ: NCLEX Client Needs Category: Health Promotion and
Maintenance
8. Which clinical management prevention concept would the nurse
identify as representative of secondary prevention?
a. Decreasing venous stasis and risk for pulmonary emboli
b. Implementation of strict hand washing routines
c. Maintaining current vaccination schedules
d. Prevention of pneumonia in patients with chronic lung disease
,Test Bank - Clinical Reasoning Cases in Nursing 10th Edition (Harding,
2024\25), All Chapters 1-72 ANSWERSHEET
ANS: D
Prevention of and treatment of existing health problems to avoid
further complications is an example of secondary prevention. Primary
prevention includes infection control (hand washing), smoking cessation,
immunizations, and prevention of postoperative complications.
MULTIPLE RESPONSE
1. The nurse would identify which body systems as directly involved in
the process of normal gas exchange? (Select all that apply.)
a. Neurologic system
b. Endocrine system
c. Pulmonary system
d. Immune system
e. Cardiovascular system
f. Hepatic system
ANS: A, C, E
The neurologic system controls respiratory drive; the respiratory
system controls delivery of oxygen to the lung capillaries; and the
cardiac system is responsible for the perfusion of vital organs. These
systems are primarily responsible for the adequacy of gas exchange in
the body. The endocrine and hepatic systems are not directly involved
with gas exchange. The immune system primarily protects the body
against infection.
2. The nurse is assessing a patient for the adequacy of ventilation.
What assessment findings would indicate the patient has good
ventilation? (Select all that apply.)
a. Respiratory rate is 24 breaths/min.
, b. Oxygen saturation level is 98%.
c. The right side of the thorax expands slightly more than the
left.
d. Trachea is just to the left of the sternal notch.
e. Nail beds are pink with good capillary refill.
f. There is presence of quiet, effortless breath sounds at lung
base bilaterally.
ANS: B, E, F
Oxygen saturation level should be between 95 and 100%; nail beds
should be pink with capillary refill of about 3 seconds; and breath
sounds should be present at base of both lungs. Normal respiratory
rate is between 12 and 20 breaths/min. The trachea should be in midline
with the sternal notch. The thorax should expand equally on both sides.
Chapter 3.Mobility
MULTIPLE CHOICE
1. A patient who has been in the hospital for several weeks is about to
be discharged. The patient is weak from the hospitalization and asks
the nurse to explain why this is happening. The nurses best response is
You are weak because
a. your iron level is low. This is known as anemia.
b. of your immobility in the hospital. This is known as
deconditioning.
c. of your poor appetite. This is known as malnutrition.
d. of your medications. This is known as drug induced weakness.
ANS: B
