Exhibits

Select the 3 assessment findings that indicate ineffective peripheral tissue perfusion for this client.

Pale skin

Capillary refill

Blood pressure

Oxygen saturation

Edema

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Surgical consent form is not signed: While a signed consent form is legally required before surgery, it can typically be obtained quickly before the procedure. It does not pose an immediate physiological threat, so it can be addressed once life-threatening abnormalities are ruled out.

B. Preoperative chest x-ray report is not available: Although the x-ray may provide important preoperative information, especially in clients with underlying conditions, its absence does not constitute an immediate risk requiring urgent action unless clinical signs suggest a problem.

C. Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L): This is a critically low potassium level (hypokalemia), which can lead to life-threatening cardiac arrhythmias during anesthesia. This electrolyte imbalance must be corrected before proceeding with surgery, making it the most urgent concern on the checklist.

D. Client's pulse oximeter reading is 96%: A SpO₂ of 96% is within normal range and does not indicate acute hypoxemia. This value requires no immediate intervention and is acceptable for proceeding with surgery, assuming no other complications are present.

A. Limit calories on days unable to exercise. B. Regular exercise with medical approval. C. Monitor blood glucose levels daily. D. Monthly appointments with the dietician.

Correct Answer is B

Explanation

A. Limit calories on days unable to exercise: While adjusting caloric intake is a useful strategy in managing blood glucose, inconsistent caloric restriction without a structured plan can lead to hypoglycemia or poor nutritional intake. This approach alone is insufficient for improving HDL levels, which are influenced more significantly by physical activity.

B. Regular exercise with medical approval: Engaging in consistent aerobic exercise enhances insulin sensitivity, helping to lower blood glucose levels. Physical activity also promotes cardiovascular health by raising HDL cholesterol, which offers protective benefits against atherosclerosis—an important concern in diabetic clients.

C. Monitor blood glucose levels daily: Daily glucose monitoring is essential for adjusting treatment and preventing complications, but it does not directly increase HDL levels. Monitoring provides data, but behavior changes like diet and exercise are what actively influence these health markers.

D. Monthly appointments with the dietician: Regular consultation with a dietitian supports nutritional management, but monthly visits may not have a timely or sufficient impact on HDL and glucose control. Lifestyle modifications, particularly regular exercise, offer more immediate and measurable effects in both areas.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Exhibits Select the 3 assessment findings that indicate ineffective peripheral tissue perfusion for this client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires Immediate action by the nurse? Reference Range: Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

Correct Answer is C

Explanation

The nurse is developing a plan of care for a client with type 2 diabetes mellitus (DM). When providing teaching on lowering blood glucose levels and increasing serum high-density lipoprotein (HDL) levels, which instruction should the nurse include?

Correct Answer is B

Explanation

An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and reports a dry mouth. Which intervention should the nurse implement?

A client is to receive progesterone 10 mg IM daily. The medication is labeled "Progesterone 50 mg/mL." How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

A client with orthopnea expresses concern about the ability to "Get enough air" during a scheduled thoracentesis. On which information should the nurse's response be based?

Which client has the highest risk for developing skin cancer?

An older adult client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. Which assessment(s) would the nurse complete to determine if a patient with type 2 diabetes mellitus (DM) is experiencing long term complications? Select all that apply

The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for?

A client with a history of asthma reports having episodes of bronchoconstriction and increased mucus production while exercising. Which action should the nurse implement?

An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?

Exhibits

Select the 3 assessment findings that indicate ineffective peripheral tissue perfusion for this client.