A client with peripheral artery disease is suffering from ineffective tissue perfusion. Which of the following would be appropriate outcomes for this nursing diagnosis? (Select all that apply)

The client will verbalize the need for adequate fluid and nutrition intake.

The client will have adequate urinary output.

The client will be free from respiratory distress.

The client’s skin will be warm and dry.

The client will have palpable peripheral pulses.

Answer and Explanation

Correct Answer : D,E

Choice A reason: Fluid and nutrition support overall health but aren’t direct outcomes for peripheral perfusion in artery disease. Warm skin and palpable pulses indicate improved circulation, making this incorrect, as it’s not specific to the nursing diagnosis of ineffective tissue perfusion.

Choice B reason: Adequate urinary output reflects renal perfusion, not peripheral artery disease’s limb perfusion. Palpable pulses are more relevant, making this incorrect, as it does not directly address the peripheral tissue perfusion outcome in the client’s nursing care plan.

Choice C reason: Respiratory distress is unrelated to peripheral artery disease, which affects limb circulation. Warm, dry skin is a perfusion outcome, making this incorrect, as it does not pertain to the nursing diagnosis of ineffective tissue perfusion in the client’s extremities.

Choice D reason: Warm and dry skin indicates improved peripheral perfusion in artery disease, reflecting better blood flow. This aligns with nursing outcomes for tissue perfusion, making it a correct outcome the nurse would expect for the client’s peripheral artery disease management.

Choice E reason: Palpable peripheral pulses demonstrate effective blood flow, a key outcome for peripheral artery disease perfusion. This aligns with vascular nursing goals, making it a correct outcome the nurse would include for the client’s ineffective tissue perfusion diagnosis.

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Correct Answer is C

Explanation

Choice A reason: Pulse pressure is calculated as systolic (90) minus diastolic (72), equaling 18 mm Hg, not 40. This is incorrect, as it overestimates the pulse pressure, unlike the nurse’s accurate calculation based on the patient’s blood pressure readings.

Choice B reason: A pulse pressure of 25 mm Hg doesn’t match the calculation of 90 minus 72, which is 18 mm Hg. This is incorrect, as it’s inaccurate compared to the nurse’s correct determination of the patient’s pulse pressure from the given values.

Choice C reason: Pulse pressure is systolic (90 mm Hg) minus diastolic (72 mm Hg), equaling 18 mm Hg. This aligns with cardiovascular assessment, making it the correct value the nurse would calculate for the patient’s blood pressure of 90/72 mm Hg.

Choice D reason: A pulse pressure of 12 mm Hg is incorrect, as 90 minus 72 equals 18 mm Hg. This underestimates the value, making it incorrect compared to the nurse’s accurate calculation of the patient’s pulse pressure based on the blood pressure.

A. Administer oxygen to the client. B. Continue dialysis at a slower rate after checking the lines for air. C. Notify the primary health care provider (PHCP) and Rapid Response Team. D. Stop dialysis, and turn the client on the left side with head lower than feet. E. Bolus the client with 500 mL of normal saline to break up the air embolus.

Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Administering oxygen improves oxygenation in air embolism, addressing hypoxia from chest pain and shortness of breath. This aligns with emergency dialysis protocols, making it a correct priority action the nurse would take to stabilize the client’s condition.

Choice B reason: Continuing dialysis, even slowly, risks worsening air embolism by introducing more air. Stopping dialysis is critical, making this incorrect, as it’s unsafe compared to the nurse’s priority of halting the procedure to prevent further embolism complications.

Choice C reason: Notifying the provider and Rapid Response Team ensures rapid intervention for air embolism, a life-threatening dialysis complication. This aligns with emergency protocols, making it a correct priority action the nurse would take to manage the client’s acute condition.

Choice D reason: Stopping dialysis and positioning the client on the left side with head down traps air in the right atrium, preventing pulmonary embolism. This is a standard intervention, making it a correct priority action for the nurse to address air embolism.

Choice E reason: Bolusing 500 mL saline doesn’t break up air emboli and risks fluid overload in kidney disease. Oxygen administration is appropriate, making this incorrect, as it’s ineffective compared to the nurse’s priority actions for managing air embolism.

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A client with peripheral artery disease is suffering from ineffective tissue perfusion. Which of the following would be appropriate outcomes for this nursing diagnosis? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient’s blood pressure is 90/72 mm Hg. What is the patient’s pulse pressure?

Correct Answer is C

Explanation

A client with chronic kidney disease being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the priority nursing actions? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

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