when assessing a client with early impairment of oxygen perfusion such as pulmonary embolus the nurse should expect to find restlessness and which of when assessing a client with early impairment of oxygen perfusion such as pulmonary embolus the nurse should expect to find restlessness and which of
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Nursing Elites

NCLEX NCLEX-PN

Quizlet NCLEX PN 2023

1. When assessing a client with early impairment of oxygen perfusion, such as a pulmonary embolus, the nurse should expect to find restlessness and which of the following symptoms?

Correct answer: tachycardia

Rationale: When a client has early impairment of oxygen perfusion, such as in a pulmonary embolus, the nurse should expect to find restlessness, diaphoresis, tachycardia, and cool skin. Tachycardia is a compensatory mechanism to increase oxygen delivery to tissues. Cool, clammy skin (choice A) is more indicative of impaired oxygen perfusion compared to warm, dry skin. Bradycardia (choice B) is less likely to occur in the early stages and is more common in severe cases. Eupnea (choice D) refers to normal respirations in rate and depth, which may not be altered in early impairment of oxygen perfusion.

2. What is the appropriate intervention for a client who is restrained?

Correct answer: Assess the restraint every 30 minutes

Rationale: The correct intervention when a client is restrained is to assess the restraint every 30 minutes. This ensures the safety and well-being of the client by checking for proper fit, circulation, and signs of distress. Removing restraints and providing skin care every hour may not be necessary and could increase the risk of skin breakdown. Documenting the skin condition every 3 hours is important but not the immediate intervention needed when a client is restrained. Tying the restraint to the side rails is unsafe and can cause harm to the client, as restraints should be secured to the bed frame or an immovable part of the bed.

3. In alcoholics with anemia:

Correct answer: Iron deficiency and folic acid deficiency can coexist.

Rationale: In alcoholics with anemia, iron deficiency and folic acid deficiency can coexist due to poor dietary intake and malabsorption issues associated with chronic alcohol consumption. Pernicious anemia, primarily related to vitamin B12 deficiency, is not commonly seen in alcoholics. While alcohol can interfere with iron absorption, it is not the sole factor contributing to anemia in alcoholics. Oral vitamin replacement is not contraindicated in alcoholics with anemia; however, it may be less effective due to absorption issues related to alcohol consumption.

4. A nurse is palpating a client’s sinus areas. Which sensation does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal?

Correct answer: Firm pressure

Rationale: The correct answer is A: Firm pressure. When the sinuses are normal, the client is expected to feel firm pressure during palpation. Pain during palpation of the sinuses is indicative of acute sinusitis, not a normal finding. Pain behind the eyes and pressure producing an acute headache are symptoms of acute sinusitis, not sensations felt during sinus palpation in normal sinuses.

5. Which of the following statements should the nurse use to best describe a very low-calorie diet (VLCD) to a client?

Correct answer: “This diet can be used when there is close medical supervision.”

Rationale: The correct answer is, “This diet can be used when there is close medical supervision.” Very low-calorie diets (VLCDs) are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality protein, and has a minimum of carbohydrates to spare protein and prevent ketosis. Choice B is incorrect because VLCDs are typically short-term interventions. Choice C is incorrect because VLCDs usually consist of nutritionally complete liquid formulations, not solid food items that are pureed. Choice D is incorrect because VLCDs actually contain a high quality of protein, although the overall caloric content is very low.

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