COMPLEX PERFUSION NCLEX PRACTICE
QUESTIONS WITH CORRECT VERIFIED ANSWERS
LATEST UPDATE
You witness the UAP placing a blood pressure cuff on your patient with an AV
fistula, on the same arm of the AV fistula, what is your next action?
a. Allow the UAP to complete the vital signs so they can be charted
b. Tell the UAP that the cuff must be placed above or below the fistula so it
doesn't touch it.
c. Stop the UAP from taking the bp on that arm and educate her on the
importance of not conducting vital signs on the same arm as the AV fistula.
d. Ensure there is a band on the affected arm stating no vitals or blood
draws/sticks are to be done on that arm. ---C what are you to do next?
Immediately stop vitals from being taken on that arm, they will possibly
damage the fistula. It doesn't matter if the cuff isn't directly over the fistula it
could still cause damage.
Your dialysis patient is about to go up for dialysis, the patient asks if they are
supposed to take all of their cardiac scheduled medications prior to dialysis,
what is your response?
a. Yes, you will need to take them before dialysis.
b. No, we will hold the medications, as they will be filtered out of the body and
wasted.
c. No we will wait till after dialysis
1
,d. We will hold the medication and give pending vital signs post dialysis. ---D,
hold the medications as they will be filtered out of the body, and they are
cardiac medications so vitals will be needed to assess if they will be given, after
dialysis it is likely the patients BP will be low, many cardiac medications lower
BP.
You're in the ED and your patient is presenting with an onset of cp, lft arm pain
and jaw pain, after completing a 12 lead you see what appears as grave stones
on many of the leads what is your next action?
a. Immediately show a Physician and call a stemi, as this is ST elevation
b. Give prescribed Nitro to improve pain
c. Call the cath lab in preparation for a stent
d. This is normal, continue on with assessment ---A, ST elevation appears to
look like gravestones on an EKG, some standing up and some will also be
upside down meaning there is reciprocation and this is likely a STEMI, the first
action is calling a stemi then all other orders follow.
Your patient has come back from the cath lab after a PCI cath procedure, you're
assessing limbs distal to cath site, the extremities are cool and clammy, what is
your next step?
a. Obtain a doppler to assess perfusion to affected limps
b. Have another nurse assess for pulses and then obtain a doppler machine to
assess for perfusion
c. Call a rapid
2
, d. Chart findings and the patients doctor ---B assess the pulses from a second
nurse, obtain a doppler machine. Do not wait to call the doctor by the time they
call back the limb may have no perfusion. Calling a rapid before gathering more
of an assessment is not appropriate.
1. A patient presents to the ED with fever, chills, night sweats and malaise, she
states she is an IV drug user and that she has also been losing weight lately. She
has petechiae and Janeway lesions on her body and upon auscultation she has a
cardiac murmur. Being that she presents all theses symptoms and is an iv drug
user this puts her at risk for what perfusion illness?
a. Infective endocarditis
b. HIV
c. Pericarditis
d. Pneumonia ---A infective endocarditis, she is an iv drug user which places
her at higher risk for this infection, she has all the marking symptoms
A patient is admitted with a medical diagnosis of acute arterial occlusion. What
documentation does the nurse expect to see in the patient's medical record?
A. Acute MI and/or atrial fibrillation within the previous weeks.
B. History of chronic venous stasis disease treated with debridement and wound
care.
C. History of Marfan syndrome or Ehlers-Danlos syndrome.
D. Episode of blunt trauma that occurred several months ago. ---Answer: A
3
QUESTIONS WITH CORRECT VERIFIED ANSWERS
LATEST UPDATE
You witness the UAP placing a blood pressure cuff on your patient with an AV
fistula, on the same arm of the AV fistula, what is your next action?
a. Allow the UAP to complete the vital signs so they can be charted
b. Tell the UAP that the cuff must be placed above or below the fistula so it
doesn't touch it.
c. Stop the UAP from taking the bp on that arm and educate her on the
importance of not conducting vital signs on the same arm as the AV fistula.
d. Ensure there is a band on the affected arm stating no vitals or blood
draws/sticks are to be done on that arm. ---C what are you to do next?
Immediately stop vitals from being taken on that arm, they will possibly
damage the fistula. It doesn't matter if the cuff isn't directly over the fistula it
could still cause damage.
Your dialysis patient is about to go up for dialysis, the patient asks if they are
supposed to take all of their cardiac scheduled medications prior to dialysis,
what is your response?
a. Yes, you will need to take them before dialysis.
b. No, we will hold the medications, as they will be filtered out of the body and
wasted.
c. No we will wait till after dialysis
1
,d. We will hold the medication and give pending vital signs post dialysis. ---D,
hold the medications as they will be filtered out of the body, and they are
cardiac medications so vitals will be needed to assess if they will be given, after
dialysis it is likely the patients BP will be low, many cardiac medications lower
BP.
You're in the ED and your patient is presenting with an onset of cp, lft arm pain
and jaw pain, after completing a 12 lead you see what appears as grave stones
on many of the leads what is your next action?
a. Immediately show a Physician and call a stemi, as this is ST elevation
b. Give prescribed Nitro to improve pain
c. Call the cath lab in preparation for a stent
d. This is normal, continue on with assessment ---A, ST elevation appears to
look like gravestones on an EKG, some standing up and some will also be
upside down meaning there is reciprocation and this is likely a STEMI, the first
action is calling a stemi then all other orders follow.
Your patient has come back from the cath lab after a PCI cath procedure, you're
assessing limbs distal to cath site, the extremities are cool and clammy, what is
your next step?
a. Obtain a doppler to assess perfusion to affected limps
b. Have another nurse assess for pulses and then obtain a doppler machine to
assess for perfusion
c. Call a rapid
2
, d. Chart findings and the patients doctor ---B assess the pulses from a second
nurse, obtain a doppler machine. Do not wait to call the doctor by the time they
call back the limb may have no perfusion. Calling a rapid before gathering more
of an assessment is not appropriate.
1. A patient presents to the ED with fever, chills, night sweats and malaise, she
states she is an IV drug user and that she has also been losing weight lately. She
has petechiae and Janeway lesions on her body and upon auscultation she has a
cardiac murmur. Being that she presents all theses symptoms and is an iv drug
user this puts her at risk for what perfusion illness?
a. Infective endocarditis
b. HIV
c. Pericarditis
d. Pneumonia ---A infective endocarditis, she is an iv drug user which places
her at higher risk for this infection, she has all the marking symptoms
A patient is admitted with a medical diagnosis of acute arterial occlusion. What
documentation does the nurse expect to see in the patient's medical record?
A. Acute MI and/or atrial fibrillation within the previous weeks.
B. History of chronic venous stasis disease treated with debridement and wound
care.
C. History of Marfan syndrome or Ehlers-Danlos syndrome.
D. Episode of blunt trauma that occurred several months ago. ---Answer: A
3
