Perfusion NUR111ADN2022

A​ 65-year-old client presents to the emergency department with a​ 3-day history of diarrhea and vomiting. The nurse notices that the​ client's pulse is 128 bpm. What is the most likely cause of the increased heart​ rate?

• Effects of medications the client has taken

• Dehydration from loss of fluids

• The​ client's age

• The​ client's age

A client has been diagnosed with borderline hypertension and is given a blood pressure monitor to take daily BP readings. What instructions would be appropriate for the nurse to give the client for taking home blood​ pressure?

• "Take blood pressure at different times every day to be sure it is not elevated at different times of the​ day."

• ​"Blood pressure should be taken before getting up in the​ morning, with the arm elevated over the level of the​ heart."

• Blood pressure readings will be erroneously high if the arm is above the level of the​ heart."

• "Rest for at least 5 minutes before taking blood pressure and at least 30 minutes after drinking caffeinated​ beverages."

A​ 45-year-old client has been diagnosed with hypertension. Which modifiable risk factor would the nurse​ assess?

• age

• sex

• family history

• stress

A surgical client is admitted to the ICU following abdominal surgery. Which clinical manifestation would the nurse recognize as an indication of decreased cardiac​ output? (Select all that​ apply.)

• increased pulse rate

• capillary refill < 3 seconds

• palpable pedal pulses

• decreased urine output

• lethargy

A client appears anxious and nervous upon entering the healthcare​ provider's office. The nurse takes a blood pressure reading and notes that it is elevated. What is the next appropriate action the nurse should​ take?

• Document the blood pressure and tell the physician the client is anxious.

• Ask the client to tell you her usual blood pressure.

• Have the client rest quietly for 5 minutes and retake the blood pressure.

• Instruct the client to calm down so accurate vital signs can be obtained.

A nurse obtains a​ client's radial pulse and notes that it is rapid and very irregular. What is the most appropriate action for the nurse to​ take?

• Document the best estimation of the pulse.

• Ask another nurse to attempt a radial pulse measurement.

• Obtain an apical pulse for 1 minute.

• Have the client lie still for 5 minutes and attempt another measurement.

A​ 62-year-old female client has been diagnosed with narrowing of the coronary arteries. What would be the​ appropriate, conservative initial treatment for this​ condition?

• Eat a diet with a minimum of​ 20% fat.

• Take statin medications as prescribed.

• Exercise for 30 minutes 3 times a week.

• Cut smoking by half the usual amount.

A nurse is performing an assessment on a​ 65-year-old client. Which subjective assessment finding could indicate a decrease in​ perfusion?

• Decreased appetite

• Nocturnal leg cramping

• Sleeping with more pillows or in a recliner

• Reporting the need for a​ mid-afternoon nap

Which is most likely to be a normal assessment finding in an​ 80-year-old client?

• Blood pressure of​ 160/90 mmHg

• Irregular heart rhythm

• Heart rate of 110​ beats/min

• Resting heart rate of 62​ beats/min

Which independent nursing intervention would be most beneficial for a client who experiences extreme shortness of breath with​ activity?

• Elevating lower extremities to prevent edema

• Promoting relaxation techniques

• Administering increased oxygen as needed with activity

• Dietary teaching