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EDAPT. Altered Perfusion Questions and Answers Graded A+
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EDAPT. Altered Perfusion
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EDAPT. Altered PerfusionThe nurse is caring for a client whose blood pressure is low. Which part of the clinical
judgment measurement model (CJMM) is the nurse performing? - answer Recognizing
a cue
The nurse is caring for a client who is experiencing shortness of breath and tachypnea
during an asthma exacerbation. Before administering oxygen, the nurse plans to elevate
the head of the bed. Which part of the clinical judgment measurement model (CJMM) is
the nurse performing? - answer Generating a solution
The nurse checks a client's blood pressure and heart rate after administering an
antihypertensive medication. Which part of the clinical judgment measurement model
(CJMM) is the nurse performing? - answer Evaluating outcomes
The nurse is caring for several clients with altered perfusion. For each assessment
finding, indicate if the finding represents altered peripheral or central perfusion. -
answer*Altered Central Perfusion:*
• Dyspnea
• Dizziness
• Tachycardia
• Chest pain
*Altered Peripheral Perfusion:*
• Decreased hair distribution on legs
• Cool, pale skin on legs
• Diminished pedal pulses
• Decreased capillary refill
The nurse is caring for a client with signs of altered central perfusion. The client is at
risk for developing __________ caused by __________. - answerMyocardial infarction
Decreased cardiac output
When caring for a client who is hospitalized with decreased central perfusion following a
myocardial infarction, which prescriptions does the nurse anticipate? Select all that
apply. - answerVasodilator medication
Vascular intervention
Supplemental oxygen
The nurse is caring for a client who reports severe pain in the lower left leg following a
femur fracture. What is the nurse's priority action at this time? - answerPerform a
peripheral vascular assessment of the left leg.
,The nurse is caring for a client who reports severe pain in the lower left leg following a
femur fracture. After medical intervention, another peripheral vascular assessment is
performed. What are signs that medical intervention has been successful? Select all
that apply. - answerPain reported as 3/10
Pedal pulse 2+ in the left foot
Left foot is pink and warm to touch
Minimal swelling of the left foot
Select the cues that require immediate follow-up by the nurse.
Julie Klaus (pronouns: she/her/hers) is a 62-year-old client who presents to the
emergency department with shortness of breath and chest pain. She has a history of
smoking, 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. - answerShortness of breath
Chest pain
Oxygen saturation 82%
Crackles in the lower lung fields
Julie Klaus (pronouns: she/her/hers) is a 62-year-old client who presents to the
emergency department with shortness of breath and chest pain. She has a history of
smoking, 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 consistent with acute heart failure. The client has
__________ caused by __________. - answerPulmonary edema
Fluid volume overloard
Julie Klaus (pronouns: she/her/hers) is a 62-year-old client who presents to the
emergency department with shortness of breath and chest pain. She has a history of
smoking, 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 nurse analyzes the assessment findings and identifies three client problems. Place
the client's problems in the correct priority order, from highest to lowest. - answer1.
Impaired gas exchange
2. Excess fluid volume
3. Ineffective peripheral tissue perfusion
Julie Klaus (pronouns: she/her/hers) is a 62-year-old client who presents to the
emergency department with shortness of breath and chest pain. She has a history of
smoking, 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.
For each potential prescription, indicate if the prescription is essential, non-essential, or
contraindicated. - answer*Essential:*
• Position in high-Fowler's.
• Administer supplemental oxygen 10 L/minute via simple face mask.
*Non-essential:*
• Perform peripheral vascular assessments on both lower extremities..
*Contraindicated:*
• Administer intravenous 0.9% sodium chloride at 150 mL/hour.
Julie Klaus (pronouns: she/her/hers) is a 62-year-old client who presents to the
emergency department with shortness of breath and chest pain. She has a history of
smoking, 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 nurse should first initiate __________ and then initiate __________. -
answerSupplemental oxygen
Fluid restriction
Julie Klaus (pronouns: she/her/hers) is a 62-year-old client who presents to the
emergency department with shortness of breath and chest pain. She has a history of
smoking, 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.
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