OXYGENATION AND PERFUSION NUR
111 (NCLEX QUESTIONS) EXAM
QUESTIONS AND ANSWERS (VERIFIED
AND UPDATED)
Which of the following assessment findings would suggest to the nurse that a Patient is at risk
for alterations in perfusion?
1. Blood pressure 110/68 mmHg
2. Apical heart rate 80; radial beats per minute 68
3. Respiratory rate 20 per minute
4. Temperature 98.8°F - ANS Answer
2. Apical heart rate 80; radial beats per minute 68.
• Rationale:
• The number of radial beats per minute is 12 beats slower than the apical rate of 80 per
minute. This indicates weak contractions of the left ventricle and could lead to alterations in
perfusion. The other assessment findings are within normal limits.
• Nursing Process: Assessment
• Cognitive Level: Analyzing
• Client Need: Physiological Integrity
A Patient is admitted with complaints of shortness of breath of 2 weeks duration. Which of the
following laboratory findings would support the finding that the Patient is at risk for an
alteration in perfusion?
@2026/2027 ALLRIGHTS RESERVED.
, 1. Increased hematocrit
2. Decreased BUN
3. Increased blood sugar
4. Increased sedimentation rate - ANS 1. Increased hematocrit.
• Rationale:
• Hematocrit is the percentage of the blood that is erythrocytes, which contain the hemoglobin
that carries oxygen. Long-term hypoxia may result in the body's attempt to increase oxygen-
carrying capacity by increasing erythrocyte production. This can lead to an alteration in the
client's perfusion. BUN is a measure of blood urea nitrogen, not oxygen-carrying capacity.
Increases in blood sugar and sedimentation rate are not directly a measure of oxygenation.
• Nursing Process: Assessment
• Cognitive Level: Analyzing
• Client Need: Physiological Integrity
• Learning Outcome: 5. Outline diagnostic and laboratory tests to determine the individual's
perfusion status.
A Patient tells the nurse that he does not want to develop the same heart problems that his
parents experienced. Which of the following should the nurse instruct this client?
1. Avoid cigarette smoking
2. Limit fluid intake
3. Wear elastic hose
4. Limit exercise to 15 minutes a day - ANS • • Answer
1. Avoid cigarette smoking
Rationale:
• The one intervention that would help the client prevent the onset of cardiovascular disease
would be to avoid cigarette smoking. Limiting fluids and wearing elastic hose are not known to
prevent the onset of cardiovascular disease. Limiting exercise to 15 minutes a day may also not
be enough exercise to prevent the onset of cardiovascular disease.
• Nursing Process: Implementation
@2026/2027 ALLRIGHTS RESERVED.
111 (NCLEX QUESTIONS) EXAM
QUESTIONS AND ANSWERS (VERIFIED
AND UPDATED)
Which of the following assessment findings would suggest to the nurse that a Patient is at risk
for alterations in perfusion?
1. Blood pressure 110/68 mmHg
2. Apical heart rate 80; radial beats per minute 68
3. Respiratory rate 20 per minute
4. Temperature 98.8°F - ANS Answer
2. Apical heart rate 80; radial beats per minute 68.
• Rationale:
• The number of radial beats per minute is 12 beats slower than the apical rate of 80 per
minute. This indicates weak contractions of the left ventricle and could lead to alterations in
perfusion. The other assessment findings are within normal limits.
• Nursing Process: Assessment
• Cognitive Level: Analyzing
• Client Need: Physiological Integrity
A Patient is admitted with complaints of shortness of breath of 2 weeks duration. Which of the
following laboratory findings would support the finding that the Patient is at risk for an
alteration in perfusion?
@2026/2027 ALLRIGHTS RESERVED.
, 1. Increased hematocrit
2. Decreased BUN
3. Increased blood sugar
4. Increased sedimentation rate - ANS 1. Increased hematocrit.
• Rationale:
• Hematocrit is the percentage of the blood that is erythrocytes, which contain the hemoglobin
that carries oxygen. Long-term hypoxia may result in the body's attempt to increase oxygen-
carrying capacity by increasing erythrocyte production. This can lead to an alteration in the
client's perfusion. BUN is a measure of blood urea nitrogen, not oxygen-carrying capacity.
Increases in blood sugar and sedimentation rate are not directly a measure of oxygenation.
• Nursing Process: Assessment
• Cognitive Level: Analyzing
• Client Need: Physiological Integrity
• Learning Outcome: 5. Outline diagnostic and laboratory tests to determine the individual's
perfusion status.
A Patient tells the nurse that he does not want to develop the same heart problems that his
parents experienced. Which of the following should the nurse instruct this client?
1. Avoid cigarette smoking
2. Limit fluid intake
3. Wear elastic hose
4. Limit exercise to 15 minutes a day - ANS • • Answer
1. Avoid cigarette smoking
Rationale:
• The one intervention that would help the client prevent the onset of cardiovascular disease
would be to avoid cigarette smoking. Limiting fluids and wearing elastic hose are not known to
prevent the onset of cardiovascular disease. Limiting exercise to 15 minutes a day may also not
be enough exercise to prevent the onset of cardiovascular disease.
• Nursing Process: Implementation
@2026/2027 ALLRIGHTS RESERVED.
