MULTIPLE CHOICE
1. The nurse is explaining to a student nurse about impaired central perfusion. The nurse
knowsthe 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
couldhave 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 havehappened.
3. The patient asks the nurse to explain the sinoatrial node in the heart. The nurses best
responsewould 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
patientis diagnosed with internal bleeding. The nurses primary concern is to monitor for
a. mental alertness.
b. perfusion.
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
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, areimportant but not the primary concern.
5. A patients serum electrolytes are being monitored. The nurse notices that the potassium
levelis 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
studentunderstands 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
smokedtwo 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
diseaseANS: 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
donot 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
atincreased risk for impaired gas exchange? A patient
a. with a blood glucose of 350 mg/dL
b. who has been on anticoagulants for 10 days
c. with a hemoglobin of 8.5 g/dL
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, d. with a heart rate of 100 beats/min and blood pressure of
100/60ANS: 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
carryingcapacity 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
onassessment 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
exchangesecondary 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
chemotherapyANS: 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
wouldthis 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.
Eosinophil cells are increased in an allergic response. Neutrophils are more indicative of an
acuteinflammatory 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
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