What is not a sign of inadequate perfusion?
Bounding pulses.
Cyanosis.
Pallor.
Coolness.
The Correct Answer is A
Bounding pulses are not a sign of inadequate perfusion.
Inadequate perfusion is when blood flow to a specific part of your body is reduced and that part will not receive essential nutrients.
Signs of inadequate perfusion include cyanosis (bluish discoloration of the skin due to lack of oxygen), pallor (paleness of the skin), and coolness1.
Choice B is incorrect because cyanosis is a sign of inadequate perfusion.
Choice C is incorrect because pallor is a sign of inadequate perfusion.
Choice D is incorrect because coolness is a sign of inadequate perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Temperature 97.0°F; pulse 54 bpm; respirations 14 breaths/minute; blood pressure 196/114 mmHg.
This set of vital signs is cause for concern because the blood pressure is significantly elevated.
A blood pressure reading of 196/114 mmHg is considered a hypertensive crisis and requires immediate medical attention.
Choice A) Temperature 96.9°F; pulse 100 bpm; respirations 20 breaths/minute; blood pressure 120/80 mmHg is within normal limits for an adult.
Choice C) Temperature 98.6°F; pulse 60 bpm; respirations 14 breaths/minute; blood pressure 110/66 mmHg is also within normal limits for an adult.
Choice D) Temperature 99°F; pulse 72 bpm; respirations 16 breaths/minute; blood pressure 100/60 mmHg is slightly elevated but not cause for immediate concern.
Correct Answer is B
Explanation
Remaining attentive but silent is an appropriate response by the nurse.
This allows the client to express their feelings and concerns without interruption or judgment.
It also shows the client that the nurse is actively listening and interested in what they have to say.
Choice A is not an appropriate response because placing a client on a 72-hour hold should only be done if the client is a danger to themselves or others.
Choice C is not an appropriate response because leaving the room immediately would be unprofessional and could make the client feel abandoned.
Choice D is not an appropriate response because telling the client that everything will be fine may not be true and could give false hope.
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