Respiratory
A patient presents with cool, pale extremities, weak pulses, and delayed capillary refill. The nurse suspects:
A. Impaired tissue perfusion
B. Increased cardiac output
C. Normal circulatory function
D. Elevated blood pressure
A. Impaired tissue perfusion
Cool, pale extremities and weak pulses indicate poor circulation and inadequate tissue perfusion.
A nurse is caring for a patient with hypertension. Which intervention is most appropriate?
A. Administer glucose IV as needed
B. Limit physical activity completely
C. Encourage sodium restriction
D. Limit physical activity completely
C. Reducing sodium intake helps lower blood pressure by decreasing fluid retention and vascular resistance.
A patient with a history of loop diuretic use reports fatigue, muscle weakness, and tingling in the extremities. The nurse suspects which electrolyte imbalance?
Correct! Hypokalemia is commonly caused by loop diuretic therapy and presents with fatigue, muscle weakness, and abnormal sensation
A patient with pulmonary edema presents with dyspnea, orthopnea, pink frothy sputum, and restlessness. What laboratory finding confirms impaired gas exchange?
A. Elevated hemoglobin levels
B. Low PaCo2 & High PaCO2
C. Increased serum sodium levels
D. Decreased pulmonary capillary pressure
C. Hypoxemia (low PaO₂) and hypercapnia (high PaCO₂) indicate impaired gas exchange in pulmonary edema
A patient with heart failure has been receiving diuretics. Which finding indicates improved perfusion?
A. Increased shortness of breath
B. Reduced peripheral edema
C. Elevated blood pressure
D. Cold and cyanotic extremities
Decreased edema suggests improved fluid balance and enhanced circulatory function.
A nurse is assessing a patient with severe dehydration. Which clinical sign is expected?
A. Increased urine output and flushed skin
B. Hypotension with moist skin
C. Generalized edema and bradycardia
D. Elevated heart rate & dry mucous membranes
Tachycardia and dry mucous membranes indicate dehydration due to reduced circulating fluid volume.
Which clinical sign suggests that a patient is experiencing severe hypoxia?
A. Cyanosis and altered mental status
B. Bradycardia and low blood pressure
C. Elevated urine output and hyperactivity
D. Increased appetite and flushed skin
A. Cyanosis and confusion result from inadequate oxygen delivery to tissues.
A nurse is evaluating a patient receiving IV fluids for hypotension. Which assessment suggests the treatment is effective?
A. Increased urine output
B. Persistent dizziness
C. Decreased capillary refill
D. Cool and clammy skin
Improved urine output indicates that kidney perfusion is restored, reflecting better circulation.
A patient with hypokalemia is prescribed oral potassium supplementation. What additional intervention should the nurse implement?
A. Encourage potassium-rich foods
B. Limit dietary sodium intake
C. Restrict oral fluid intake
D. Administer diuretics as prescribed
A. Encouraging potassium-rich foods like bananas and orange juice helps maintain adequate potassium levels .
A patient with hypocalcemia has been receiving calcium supplements. Which assessment finding indicates treatment is effective?
A. Development of tingling and numbness
B. New onset of cardiac arrhythmias
C. Absence of muscle spasms and Chvostek’s sign
D. Increased deep tendon reflexes
C. Relief of muscle spasms and negative Chvostek’s sign indicate improved calcium balance.
A nurse is evaluating the fluid status of a patient receiving IV fluids for dehydration. Which finding suggests treatment is effective?
A. Balanced intake and output
B. Increased urine specific gravity
C. Persistent postural dizziness
D. Decreased blood pressure
A. Balanced intake and output indicate effective fluid replacement and homeostasis .