Exhibits
Select the 3 assessment findings that indicate ineffective peripheral tissue perfusion for this client.
Pale skin
Capillary refill
Blood pressure
Oxygen saturation
Edema
Correct Answer : A,B,E
A. Pale skin: Pallor is a classic sign of reduced peripheral circulation and suggests inadequate oxygenated blood flow to the tissues. In the context of amputation and peripheral vascular disease, pale skin near the residual limb may reflect compromised perfusion and should be closely monitored for signs of ischemia or delayed healing.
B. Capillary refill: Delayed capillary refill (greater than 2 seconds) is an indicator of impaired tissue perfusion and poor blood flow to the periphery. A capillary refill time of 4 seconds is significantly prolonged indicating delayed peripheral circulation which is a key marker of ineffective peripheral tissue perfusion.
C. Blood pressure: The client’s blood pressure is within normal limits (126/84 mm Hg) and does not suggest systemic hypoperfusion. While hypotension can impact tissue perfusion, this stable BP supports adequate central circulation and is not directly indicative of peripheral perfusion issues.
D. Oxygen saturation: An oxygen saturation of 95% on room air reflects adequate oxygenation at the systemic level. Peripheral tissue perfusion issues are localized and may not always be evident in systemic oxygen saturation readings unless accompanied by widespread circulatory compromise.
E. Edema: The presence of edema around the incision may indicate impaired lymphatic or venous return, which can hinder oxygen and nutrient delivery to tissues. Edema is a common sign of ineffective peripheral perfusion. Localized swelling around the incision can impair oxygen and nutrient exchange in the tissues by increasing interstitial pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
Calculation:
Total volume to be infused = 100 mL
Infusion time in hours:
Infusion time (hours) = Infusion time (minutes) / 60 minutes/hour
= 30 minutes / 60 minutes/hour
= 0.5 hours
Calculate the infusion rate in mL/hour:
Infusion rate (mL/hour) = Total volume (mL) / Infusion time (hours)
= 100 mL / 0.5 hours
= 200 mL/hour
Correct Answer is D
Explanation
A. Radiating, sharp pain in right shoulder: This pain is a common symptom of gallbladder inflammation or biliary colic due to referred pain from diaphragmatic irritation. While it should be documented and managed for comfort, it is not immediately life-threatening or indicative of worsening complications.
B. Clay colored stool: Pale or clay-colored stools occur when bile flow into the intestines is obstructed, leading to a lack of stercobilin, the pigment responsible for stool color. This finding confirms bile duct obstruction but is expected in the context of cholelithiasis with jaundice and doesn’t require urgent intervention.
C. Bile stained emesis: Vomiting bile indicates upper gastrointestinal involvement and is often associated with prolonged nausea due to gallbladder or liver pathology. While uncomfortable and noteworthy, it is not as alarming as signs of acute abdominal complications.
D. Distended, hard, and rigid abdomen: This finding suggests peritonitis or a perforated viscus, which are surgical emergencies. A rigid abdomen indicates guarding and possible internal inflammation or infection, requiring immediate medical evaluation and intervention to prevent rapid deterioration.
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