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: Clamping the T-tube risks bile backup and infection, especially with 750 mL drainage. Notifying the surgeon addresses potential complications, making this incorrect, as it’s unsafe compared to the nurse’s priority of reporting excessive T-tube output.

Choice B reason: Irrigating the T-tube without medical orders risks dislodging it or causing infection. Notifying the surgeon is appropriate for 750 mL drainage, making this incorrect, as it’s risky compared to the nurse’s action to seek medical evaluation.

Choice C reason: Notifying the surgeon is most appropriate, as 750 mL of T-tube drainage may indicate a complication like bile leak or obstruction. This aligns with post-surgical care protocols, making it the correct intervention for the nurse to address excessive drainage.

Choice D reason: Documenting is necessary but doesn’t address the potential complication of 750 mL drainage. Notifying the surgeon is urgent, making this incorrect, as it delays the nurse’s priority of reporting a significant post-surgical T-tube output to the surgeon.

A. Inverted T waves. B. Peaked T wave. C. Elevated troponin I. D. Elevated troponin T.

Correct Answer is C

Explanation

Choice A reason: Inverted T waves suggest ischemia but are less specific than troponin I, which confirms myocardial damage in ACS. This is incorrect, as it’s not the most significant finding within 3 hours compared to the nurse’s reliance on biomarkers for diagnosis.

Choice B reason: Peaked T waves indicate hyperkalemia, not ACS, which is diagnosed by troponin elevation. This is incorrect, as it’s unrelated to the nurse’s expected finding for acute coronary syndrome within the first 3 hours of symptom onset.

Choice C reason: Elevated troponin I is the most significant finding for ACS, indicating myocardial necrosis within 3 hours. This aligns with diagnostic criteria, making it the correct biomarker the nurse would prioritize to confirm acute coronary syndrome in the client.

Choice D reason: Troponin T is also specific for ACS but rises slightly later than troponin I, which is detectable sooner. This is incorrect, as troponin I is more significant within 3 hours for the nurse’s diagnosis of acute coronary syndrome.

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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)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

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