OXYGENATION AND PERFUSION NUR 111 (NCLEX QUESTIONS) WITH CORREC ANSWERS
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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 pe... r minute 68 3. Respiratory rate 20 per minute 4. Temperature 98.8°F Correct Answer 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 Correct Answer 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. 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 [Show More]
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