Exam 16: Perfusion

A client with disseminated intravascular coagulation (DIC)is anxious and has decreased oxygen saturation.Which is the priority nursing diagnosis for this client?

A client diagnosed with a deep vein thrombosis (DVT)is receiving intravenous heparin.Which is the priority outcome for this client?

The nursing diagnosis Noncompliance related to unknown factors is established for a client with hypertension who admits to occasionally taking prescribed antihypertensive medications.Which behavior should the nurse demonstrate when discussing reasons for noncompliance with this client?

A client with sepsis has a temperature of 40°Celsius.Which potentially life-threatening dysrhythmia is most likely to occur in this client?

The nurse has instructed a client recovering from a pulmonary embolism on long-term anticoagulant therapy.Which client statement indicates that instruction has been effective?

A client with a history of myocardial infarctions states to the nurse,"I have been smoking for 35 years.It will not matter if I stop now." Which is the priority response from the nurse?

While completing a health history with an older adult client,the nurse learns that the client experienced a transient ischemic attack (TIA)several months ago.What does this information suggest to the nurse?

The nurse is caring for a child with disseminated intravascular coagulation (DIC).Which is a priority intervention for this child?

The home care nurse assesses an older adult client's blood pressure as being 150/100 mmHg.When reviewing medications,the client reports taking the blood pressure medication only when feeling tense.Which instruction from the nurse is most appropriate based on the data provided?

A nurse is caring for a client suspected of a cocaine-induced myocardial infarction (MI).When asked to describe how cocaine can induce an MI,which rationale will the nurse use to respond?

The nurse is planning care for an infant with congestive heart failure (CHF).What should the nurse include in this child's care?

A nurse working in the intensive care unit (ICU)is caring for a client in a hypertensive emergency due to acute nephritis.When discussing this data with a novice nurse during change of shift report,which statement by the nurse is appropriate when discussing the effects of the renal system on the client's blood pressure?

A client diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea.Which is the priority nursing diagnosis for this client?

A nurse working in the newborn nursery is assessing a term baby for congenital heart defects.Which clinical manifestations would indicate an atrial septal defect (ASD)? Select all that apply.