NUR 114 Perfusion Test Verified Questions And
Answers With Latest Updates
A nurse is caring for a client with hypertension. Which assessment finding most significantly indicates that a
client is hypertensive?
1. Tachycardia
2. Extended Korotkoff sound
3. Sustained systolic pressure ranging from 110 to 120 mm Hg
4. Diastolic blood pressure that remains higher than 90 mm Hg ANS 4
R: A sustained diastolic pressure that exceeds 90 mm
While the nurse moves a client from a lying to standing position, the client experiences a rapid drop in blood
pressure. The nurse would report this finding as what?
1. Malignant hypotension
2. Orthostatic dehydration
3. Orthostatic hypotension
4. Vasomotor instability ANS 3
Orthostatic hypotension specifically refers to an abnormally low blood pressure that occurs when an individual
assumes a standing position. Orthostatic hypotension is also known as postural hypotension. It may be a result
of internal bleeding, fluid depletion, or loss of neurovascular control preventing vasoconstriction from
regulating blood pressure.
A client with type 1 diabetes asks what causes the several brown spots on the skin. What would be the best
response by the nurse?
1. "The brown spots reflect the accumulation of blood fats in the skin; they should disappear."
2. "Those spots indicate a high glucose content in the skin that may get infected if left untreated."
"3. They are the result of diseased small vessels in the shins and may spread if not treated soon."
4. "Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown
spot." ANS 4
"Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown
spot" is an accurate explanation for the client's concern; brown spots are caused by the deposit of hemosiderin
in the tissue. Brown spots reflecting the accumulation of blood fats in the skin and disappearing is the
definition of a xanthoma
, A client is admitted with a diagnosis of a ruptured spleen. The client's blood pressure is 100/60 mm Hg. What
should the nurse assess in the client as an early sign of decreased arterial pressure?
1 Weak radial pulses
2 Warm, flushed skin
3 Lethargy with confusion
4 Increased pulse pressure ANS 1
Hypovolemia occurs with decreased cardiac output; the resulting decreased arterial pressure is reflected in
weak, thready peripheral pulses. The skin will be cool and pale because of vasoconstriction. Lethargy with
confusion will occur later as a result of hypovolemic shock. The pulse pressure will be decreased, not
increased, with decreased cardiac output associated with hypovolemic shock.
A nurse is teaching a client about the normal pathway followed during the cardiac cycle. In which sequence
should the nurse list the structures, beginning with the first?
1.Bundle of His
2.Purkinje fibers
3.Atrioventricular node
4.Bundle branches
5.Sinoatrial node ANS 5,3,1,4,2
SA node -> AV node -> Bundle of His -> Bundle Branches -> Purkinjie fibers
A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias.
Which reason for increased incidence of dysrhythmias in this client should the nurse monitor?
1. Metabolic alkalosis
2. Myocardial hypoxia
3. Decreased catecholamine secretion
4. Increased parasympathetic nervous system stimulation ANS 2.
Dysrhythmias are common and result from decreased oxygen to the cells of the myocardium. Myocardial
infarction with tissue necrosis results in metabolic acidosis, not metabolic alkalosis. When physical or
emotional stress is experienced, such as in an MI, catecholamine secretion increases; this is part of the "fight or
flight" mechanism. Increased sympathetic, not parasympathetic, nervous system stimulation may contribute to
the development of dysrhythmias.
The primary healthcare provider prescribes "bathroom privileges only" for a client with pulmonary edema. The
client becomes irritable and asks the nurse whether it is really necessary to stay in bed so much. What would
be the best reply by the nurse?
Answers With Latest Updates
A nurse is caring for a client with hypertension. Which assessment finding most significantly indicates that a
client is hypertensive?
1. Tachycardia
2. Extended Korotkoff sound
3. Sustained systolic pressure ranging from 110 to 120 mm Hg
4. Diastolic blood pressure that remains higher than 90 mm Hg ANS 4
R: A sustained diastolic pressure that exceeds 90 mm
While the nurse moves a client from a lying to standing position, the client experiences a rapid drop in blood
pressure. The nurse would report this finding as what?
1. Malignant hypotension
2. Orthostatic dehydration
3. Orthostatic hypotension
4. Vasomotor instability ANS 3
Orthostatic hypotension specifically refers to an abnormally low blood pressure that occurs when an individual
assumes a standing position. Orthostatic hypotension is also known as postural hypotension. It may be a result
of internal bleeding, fluid depletion, or loss of neurovascular control preventing vasoconstriction from
regulating blood pressure.
A client with type 1 diabetes asks what causes the several brown spots on the skin. What would be the best
response by the nurse?
1. "The brown spots reflect the accumulation of blood fats in the skin; they should disappear."
2. "Those spots indicate a high glucose content in the skin that may get infected if left untreated."
"3. They are the result of diseased small vessels in the shins and may spread if not treated soon."
4. "Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown
spot." ANS 4
"Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown
spot" is an accurate explanation for the client's concern; brown spots are caused by the deposit of hemosiderin
in the tissue. Brown spots reflecting the accumulation of blood fats in the skin and disappearing is the
definition of a xanthoma
, A client is admitted with a diagnosis of a ruptured spleen. The client's blood pressure is 100/60 mm Hg. What
should the nurse assess in the client as an early sign of decreased arterial pressure?
1 Weak radial pulses
2 Warm, flushed skin
3 Lethargy with confusion
4 Increased pulse pressure ANS 1
Hypovolemia occurs with decreased cardiac output; the resulting decreased arterial pressure is reflected in
weak, thready peripheral pulses. The skin will be cool and pale because of vasoconstriction. Lethargy with
confusion will occur later as a result of hypovolemic shock. The pulse pressure will be decreased, not
increased, with decreased cardiac output associated with hypovolemic shock.
A nurse is teaching a client about the normal pathway followed during the cardiac cycle. In which sequence
should the nurse list the structures, beginning with the first?
1.Bundle of His
2.Purkinje fibers
3.Atrioventricular node
4.Bundle branches
5.Sinoatrial node ANS 5,3,1,4,2
SA node -> AV node -> Bundle of His -> Bundle Branches -> Purkinjie fibers
A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias.
Which reason for increased incidence of dysrhythmias in this client should the nurse monitor?
1. Metabolic alkalosis
2. Myocardial hypoxia
3. Decreased catecholamine secretion
4. Increased parasympathetic nervous system stimulation ANS 2.
Dysrhythmias are common and result from decreased oxygen to the cells of the myocardium. Myocardial
infarction with tissue necrosis results in metabolic acidosis, not metabolic alkalosis. When physical or
emotional stress is experienced, such as in an MI, catecholamine secretion increases; this is part of the "fight or
flight" mechanism. Increased sympathetic, not parasympathetic, nervous system stimulation may contribute to
the development of dysrhythmias.
The primary healthcare provider prescribes "bathroom privileges only" for a client with pulmonary edema. The
client becomes irritable and asks the nurse whether it is really necessary to stay in bed so much. What would
be the best reply by the nurse?
