EDAPT: Altered Perfusion Test Questions and Answers Rated A
1. The nurse is caring for a client whose blood Recognizing a cue
pressure is low. Which part of the clinical
judgment measurement model (CJMM) is
the nurse performing?
2. The nurse is caring for a client who is ex- Generating a solution
periencing shortness of breath and tachyp-
nea during an asthma exacerbation. Before
administering oxygen, the nurse plans to el-
evate the head of the bed. Which part of
the clinical judgment measurement model
(CJMM) is the nurse performing?
3. The nurse checks a client's blood pressure Evaluating outcomes
and heart rate after administering an an-
tihypertensive medication. Which part of
the clinical judgment measurement model
(CJMM) is the nurse performing?
4. The nurse is caring for several clients with *Altered Central Perfusion:*
altered perfusion. For each assessment find- • Dyspnea
ing, indicate if the finding represents altered • Dizziness
peripheral or central perfusion. • Tachycardia
• Chest pain
*Altered Peripheral Perfusion:*
• Decreased hair distribution on legs
• Cool, pale skin on legs
• Diminished pedal pulses
• Decreased capillary refill
5. The nurse is caring for a client with signs Myocardial infarction
of altered central perfusion. The client is Decreased cardiac output
, EDAPT: Altered Perfusion Test Questions and Answers Rated A
at risk for developing caused by
.
6. When caring for a client who is hospitalized Vasodilator medication
with decreased central perfusion following Vascular intervention
a myocardial infarction, which prescriptions Supplemental oxygen
does the nurse anticipate? Select all that ap-
ply.
7. The nurse is caring for a client who reports Perform a peripheral vascular assess-
severe pain in the lower left leg following a ment of the left leg.
femur fracture. What is the nurse's priority
action at this time?
8. The nurse is caring for a client who reports Pain reported as 3/10
severe pain in the lower left leg following a
femur fracture. After medical intervention, Pedal pulse 2+ in the left foot
another peripheral vascular assessment is
Left foot is pink and warm to touch
performed. What are signs that medical in-
tervention has been successful? Select all
Minimal swelling of the left foot
that apply.
9. Select the cues that require immediate fol- Shortness of breath
low-up by the nurse. Chest pain
Oxygen saturation 82%
Julie Klaus (pronouns: she/her/hers) is a Crackles in the lower lung fields
62-year-old client who presents to the emer-
gency department with shortness of breath
and chest pain. She has a history of smok-
ing, heart failure, asthma, and gastric ulcers.
Julie's body mass index is 32.
Vital signs are T: 99.2 °F (37.3 °C), P: 110, BP:
, EDAPT: Altered Perfusion Test Questions and Answers Rated A
159/89, and oxygen saturation 82% on room
air. Assessment reveals crackles in the lower
lung fields and pitting edema in the lower
extremities. Potassium level is 3.6 mEq/L.
10. Julie Klaus (pronouns: she/her/hers) is a Pulmonary edema
62-year-old client who presents to the emer- Fluid volume overloard
gency department with shortness of breath
and chest pain. She has a history of smok-
ing, heart failure, asthma, and gastric ulcers.
Julie's body mass index is 32.
Vital signs are T: 99.2 °F (37.3 °C), P: 110, BP:
159/89, and oxygen saturation 82% on room
air. Assessment reveals crackles in the lower
lung fields and pitting edema in the lower
extremities. Potassium level is 3.6 mEq/L.
The client has clinical manifestations consis-
tent with acute heart failure. The client has
caused by .
11. Julie Klaus (pronouns: she/her/hers) is a 1. Impaired gas exchange
62-year-old client who presents to the emer- 2. Excess fluid volume
gency department with shortness of breath 3. Inettective peripheral tissue perfusion
and chest pain. She has a history of smok-
ing, heart failure, asthma, and gastric ulcers.
Julie's body mass index is 32.
Vital signs are T: 99.2 °F (37.3 °C), P: 110, BP:
159/89, and oxygen saturation 82% on room
air. Assessment reveals crackles in the lower
lung fields and pitting edema in the lower
1. The nurse is caring for a client whose blood Recognizing a cue
pressure is low. Which part of the clinical
judgment measurement model (CJMM) is
the nurse performing?
2. The nurse is caring for a client who is ex- Generating a solution
periencing shortness of breath and tachyp-
nea during an asthma exacerbation. Before
administering oxygen, the nurse plans to el-
evate the head of the bed. Which part of
the clinical judgment measurement model
(CJMM) is the nurse performing?
3. The nurse checks a client's blood pressure Evaluating outcomes
and heart rate after administering an an-
tihypertensive medication. Which part of
the clinical judgment measurement model
(CJMM) is the nurse performing?
4. The nurse is caring for several clients with *Altered Central Perfusion:*
altered perfusion. For each assessment find- • Dyspnea
ing, indicate if the finding represents altered • Dizziness
peripheral or central perfusion. • Tachycardia
• Chest pain
*Altered Peripheral Perfusion:*
• Decreased hair distribution on legs
• Cool, pale skin on legs
• Diminished pedal pulses
• Decreased capillary refill
5. The nurse is caring for a client with signs Myocardial infarction
of altered central perfusion. The client is Decreased cardiac output
, EDAPT: Altered Perfusion Test Questions and Answers Rated A
at risk for developing caused by
.
6. When caring for a client who is hospitalized Vasodilator medication
with decreased central perfusion following Vascular intervention
a myocardial infarction, which prescriptions Supplemental oxygen
does the nurse anticipate? Select all that ap-
ply.
7. The nurse is caring for a client who reports Perform a peripheral vascular assess-
severe pain in the lower left leg following a ment of the left leg.
femur fracture. What is the nurse's priority
action at this time?
8. The nurse is caring for a client who reports Pain reported as 3/10
severe pain in the lower left leg following a
femur fracture. After medical intervention, Pedal pulse 2+ in the left foot
another peripheral vascular assessment is
Left foot is pink and warm to touch
performed. What are signs that medical in-
tervention has been successful? Select all
Minimal swelling of the left foot
that apply.
9. Select the cues that require immediate fol- Shortness of breath
low-up by the nurse. Chest pain
Oxygen saturation 82%
Julie Klaus (pronouns: she/her/hers) is a Crackles in the lower lung fields
62-year-old client who presents to the emer-
gency department with shortness of breath
and chest pain. She has a history of smok-
ing, heart failure, asthma, and gastric ulcers.
Julie's body mass index is 32.
Vital signs are T: 99.2 °F (37.3 °C), P: 110, BP:
, EDAPT: Altered Perfusion Test Questions and Answers Rated A
159/89, and oxygen saturation 82% on room
air. Assessment reveals crackles in the lower
lung fields and pitting edema in the lower
extremities. Potassium level is 3.6 mEq/L.
10. Julie Klaus (pronouns: she/her/hers) is a Pulmonary edema
62-year-old client who presents to the emer- Fluid volume overloard
gency department with shortness of breath
and chest pain. She has a history of smok-
ing, heart failure, asthma, and gastric ulcers.
Julie's body mass index is 32.
Vital signs are T: 99.2 °F (37.3 °C), P: 110, BP:
159/89, and oxygen saturation 82% on room
air. Assessment reveals crackles in the lower
lung fields and pitting edema in the lower
extremities. Potassium level is 3.6 mEq/L.
The client has clinical manifestations consis-
tent with acute heart failure. The client has
caused by .
11. Julie Klaus (pronouns: she/her/hers) is a 1. Impaired gas exchange
62-year-old client who presents to the emer- 2. Excess fluid volume
gency department with shortness of breath 3. Inettective peripheral tissue perfusion
and chest pain. She has a history of smok-
ing, heart failure, asthma, and gastric ulcers.
Julie's body mass index is 32.
Vital signs are T: 99.2 °F (37.3 °C), P: 110, BP:
159/89, and oxygen saturation 82% on room
air. Assessment reveals crackles in the lower
lung fields and pitting edema in the lower
