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Perfusion NCLEX Questions and Answers (100%
Correct Answers)
The nurse has completed an assessment on a client with a decreased cardiac output.
Which findings should receive highest priority?
a. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles
b. Confusion, urine output 15mL over the last 2 hours, orthopnea.
c. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities.
d. Weight gain of 1kg in 3 days, BP 130/80, mild dyspnea with exercise.
Ans: b. A low urine output and confusion are signs of decreased tissue perfusion.
Orthopnea is a sign of left-sided heart failure. Crackles, edema and weight gain
should be monitored closely, but the levels are not as high a priority. With atrial
fibrillation there is a loss of atrial kick, but the blood pressure and heart rate are
stable
Which of the following is an expected outcome when a client is receiving an IV
administration of furosemide?
a. Increased blood pressure
b. Increased urine output
c. Decreased pain
d. Decreased premature ventricular contractions
Ans: b. Furosemide is a loop diuretic that acts to increase urine output. Furosemide
does not increase blood pressure, decrease pain, or decrease arrhythmias
The nurse is assessing clients at a health fair. Which client is at greatest risk for
coronary artery disease?
a. a 32-year-old female with mitral valve prolapse who quit smoking 10 years ago.
b. a 43-year-old male with a family history of CAD and cholesterol level of 158
c. A 56-year-old male with an HDL of 60 who takes atorvastatin (Lipitor)
d. A 65-year-old female who is obese with an LDL of 188
Ans: d. The woman who is 65-years-old, over weight and has an elevated LDL is at
greatest risk. Total cholesterol >200, LDL >100, HDL <40 in men, HDL <50 in women,
men 45-years and older, women 55-years and older, smoking and obesity increase
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the risk of CAD. Atorvastatin is a medication to reduce LDL and decrease risk of CAD.
The combination of postmenopausal, obesity and high LDL cholesterol places this
client at greatest risk.
A 58-year-old female with a family history of CAD is being seen for her annual
physical exam. Fasting lab test results include: Total cholesterol 198; LDL cholesterol
120; HDL cholesterol 58; Triglycerides 148; Blood sugar 102; and C-reactive protein
(CRP) 4.2. The health care provider informs the client that she will be started on a
statin medication and aspirin. The client asks the nurse why she needs to take these
medications. Which is the best response by the nurse?
a. "The labs indicate severe hyperlipidemia and the medications will lower your LDL,
along with a low-fat diet."
b. "The triglycerides are elevated and will not return to normal without these
medications."
c. "The CRP is elevated indicating inflammation seen in cardiovascular disease, which
can be lowered by the medications ordered."
d. "The medications are not indicated since your lab values are all normal."
Ans: c. CRP is a marker of inflammation and is elevated in the presence of
cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater
accuracy in measuring the CRP to evaluate cardiovascular risk. The family history,
post-menopausal age, LDL above optimum levels and elevated CRP place the client at
risk of CAD. Statin medications can decrease LDL, whereas statins and aspirin can
reduce CRP and decrease the risk of MI and stroke.
An older, sedentary adult may not respond to emotional or physical stress as well as
a younger individual because of:
a. Left ventricular atrophy
b. Irregular heartbeats
c. Peripheral vascular occlusion
d. Pacemaker placement
Ans: a. In older adults who are less active and do not exercise the heart muscle,
atrophy can result. Disuse or deconditioning can lead to abnormal changes in the
myocardium of the older adult. As a result, under sudden emotional or physical
stress, the left ventricle is less able to respond to the increased demands on the
myocardial muscle. Decreased cardiac output, cardiac hypertrophy, and heart failure
are examples of the chronic conditions that may develop in response to inactivity,
rather than in response to the aging process. Irregular heartbeats are generally not
associated with an older sedentary adult's lifestyle. Peripheral vascular occlusion or
pacemaker placement should not affect response to stress.
Perfusion NCLEX Questions and Answers (100%
Correct Answers)
The nurse has completed an assessment on a client with a decreased cardiac output.
Which findings should receive highest priority?
a. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles
b. Confusion, urine output 15mL over the last 2 hours, orthopnea.
c. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities.
d. Weight gain of 1kg in 3 days, BP 130/80, mild dyspnea with exercise.
Ans: b. A low urine output and confusion are signs of decreased tissue perfusion.
Orthopnea is a sign of left-sided heart failure. Crackles, edema and weight gain
should be monitored closely, but the levels are not as high a priority. With atrial
fibrillation there is a loss of atrial kick, but the blood pressure and heart rate are
stable
Which of the following is an expected outcome when a client is receiving an IV
administration of furosemide?
a. Increased blood pressure
b. Increased urine output
c. Decreased pain
d. Decreased premature ventricular contractions
Ans: b. Furosemide is a loop diuretic that acts to increase urine output. Furosemide
does not increase blood pressure, decrease pain, or decrease arrhythmias
The nurse is assessing clients at a health fair. Which client is at greatest risk for
coronary artery disease?
a. a 32-year-old female with mitral valve prolapse who quit smoking 10 years ago.
b. a 43-year-old male with a family history of CAD and cholesterol level of 158
c. A 56-year-old male with an HDL of 60 who takes atorvastatin (Lipitor)
d. A 65-year-old female who is obese with an LDL of 188
Ans: d. The woman who is 65-years-old, over weight and has an elevated LDL is at
greatest risk. Total cholesterol >200, LDL >100, HDL <40 in men, HDL <50 in women,
men 45-years and older, women 55-years and older, smoking and obesity increase
, 2 Inquire through: | Professional | Confidential Support
the risk of CAD. Atorvastatin is a medication to reduce LDL and decrease risk of CAD.
The combination of postmenopausal, obesity and high LDL cholesterol places this
client at greatest risk.
A 58-year-old female with a family history of CAD is being seen for her annual
physical exam. Fasting lab test results include: Total cholesterol 198; LDL cholesterol
120; HDL cholesterol 58; Triglycerides 148; Blood sugar 102; and C-reactive protein
(CRP) 4.2. The health care provider informs the client that she will be started on a
statin medication and aspirin. The client asks the nurse why she needs to take these
medications. Which is the best response by the nurse?
a. "The labs indicate severe hyperlipidemia and the medications will lower your LDL,
along with a low-fat diet."
b. "The triglycerides are elevated and will not return to normal without these
medications."
c. "The CRP is elevated indicating inflammation seen in cardiovascular disease, which
can be lowered by the medications ordered."
d. "The medications are not indicated since your lab values are all normal."
Ans: c. CRP is a marker of inflammation and is elevated in the presence of
cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater
accuracy in measuring the CRP to evaluate cardiovascular risk. The family history,
post-menopausal age, LDL above optimum levels and elevated CRP place the client at
risk of CAD. Statin medications can decrease LDL, whereas statins and aspirin can
reduce CRP and decrease the risk of MI and stroke.
An older, sedentary adult may not respond to emotional or physical stress as well as
a younger individual because of:
a. Left ventricular atrophy
b. Irregular heartbeats
c. Peripheral vascular occlusion
d. Pacemaker placement
Ans: a. In older adults who are less active and do not exercise the heart muscle,
atrophy can result. Disuse or deconditioning can lead to abnormal changes in the
myocardium of the older adult. As a result, under sudden emotional or physical
stress, the left ventricle is less able to respond to the increased demands on the
myocardial muscle. Decreased cardiac output, cardiac hypertrophy, and heart failure
are examples of the chronic conditions that may develop in response to inactivity,
rather than in response to the aging process. Irregular heartbeats are generally not
associated with an older sedentary adult's lifestyle. Peripheral vascular occlusion or
pacemaker placement should not affect response to stress.
