Exam (elaborations)
Perfusion Module 16 Questions and Answers 2024
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Exam of 9 pages for the course Perfusion at Perfusion (Perfusion Module 16)
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Perfusion Module 16A 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?
A. Stress from being sick
B. Effects of medications the client has taken
C. The client's age
D. Dehydration from loss of fluids - answerD. Dehydration from loss of fluids
Rationale: Pulse rate will increase in response to hypovolemia to maintain an adequate
cardiac output. Factors such as stress, age, medications, exercise, and lifestyle can
alter a person's pulse. In this scenario, the client had a history of diarrhea and vomiting
and likely was experiencing hypovolemia. The nurse should expect to begin IV fluid
hydration.
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?
A. "Blood pressure readings will be erroneously high if the arm is above the level of the
heart."
B. "Rest for at least 5 minutes before taking blood pressure and at least 30 minutes
after drinking caffeinated beverages."
C. "Take blood pressure at different times every day to be sure it is not elevated at
different times of the day."
D. "Blood pressure should be taken before getting up in the morning, with the arm
elevated over the level of the heart." - answerB. "Rest for at least 5 minutes before
taking blood pressure and at least 30 minutes after drinking caffeinated beverages."
Rationale: The American Heart Association recommends clients who monitor blood
pressure at home do so with an automatic BP cuff. Measurements should be taken with
the client seated, having rested for at least 5 minutes prior, and at least 30 minutes after
drinking caffeinated beverages. Blood pressure should be taken at about the same time
each day, and the client should keep a log of blood pressure readings. Blood pressure
, readings will be erroneously low if the blood pressure is taken with the arm above the
level of the heart.
A 45-year-old client has been diagnosed with hypertension. Which modifiable risk factor
would the nurse assess?
A. Stress
B. Family History
C. Sex
D. Age - answerA. Stress
Rationale: There are numerous risk factors for development of hypertension. Certain
risk factors that cannot be modified include age, sex, family history, and ethnicity. Men,
African Americans, and those over 65 have an increased risk of developing
hypertension, as well as those with a significant family history of heart disease.
Modifiable risk factors include lifestyle choices, such as smoking, stress, sedentary
lifestyle, and high-fat diet. The nurse should discuss lifestyle management with clients
who are at risk for hypertension.
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.)
A. Capillary refill less than 3 seconds
B. Palpable pedal pulses
C. Increased pulse rate
D. Decreased urine output
E. Lethargy - answerChecking rationale with Paula
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?
A. Instruct the client to calm down so accurate vital signs can be obtained.
B. Have the client rest quietly for 5 minutes and retake the blood pressure.
C. Document the blood pressure and tell the physician the client is anxious.
D. Ask the client to tell you her usual blood pressure - answerRationale: Clients may be
anxious when seeking medical care in a physician's office. If a client appears anxious
and the nurse obtains an elevated blood pressure reading, the nurse should promote a
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