Perfusion

Question 1

Which of the following factors directly influences stroke volume?

A. Blood viscosity
B. Fluid volume status
C. Peripheral vascular resistance
D. Heart rate

Answer 1

Answer: B. Fluid volume status

Rationale: Stroke volume is the amount of blood ejected by the heart during one contraction, and it is affected by the fluid volume status in the body. If there is too little or too much fluid, stroke volume is impacted

Question 2

Which heart sound is heard due to the closure of the mitral and tricuspid valves?
A. S1
B. S2
C. S3
D. S4

Answer 2

Answer: A. S1

Rationale: S1 is the “lub” sound, which occurs when the mitral and tricuspid valves close during systole

Question 3

Central perfusion refers to the perfusion specific to the cardiopulmonary system.

Answer 3

Answer: True

Rationale: Central perfusion refers to the blood flow specific to the heart and lungs, which is crucial for maintaining overall circulation​

Question 4

Which of the following is considered a modifiable risk factor for altered perfusion?

A. Gender
B. Race
C. Diet
D. Age

Answer 4

Answer: C. Diet

Rationale: Diet is a modifiable risk factor because individuals can make changes to their diet to improve or protect perfusion. Gender, race, and age are non-modifiable risk factors

Question 5

Which of the following are cues of central perfusion issues? (Select all that apply)

A. Dyspnea
B. Ischemic chest pain
C. Diminished peripheral pulses
D. Decreased capillary refill
E. Altered blood pressure

Answer 5

Answers: A. Dyspnea, B. Ischemic chest pain, E. Altered blood pressure

Rationale: Central perfusion issues primarily involve the heart and lungs, presenting with symptoms such as dyspnea (difficulty breathing), ischemic pain (chest pain), and abnormal blood pressure. Peripheral pulses and capillary refill are associated with peripheral perfusion

Question 6

Which of the following measurements is required to calculate cardiac output?

A. Blood pressure and heart rate
B. Stroke volume and heart rate
C. Stroke volume and systolic blood pressure
D. Blood pressure and peripheral resistance

Answer 6

Answer: B. Stroke volume and heart rate

Rationale: Cardiac output is the product of stroke volume (the amount of blood pumped by the ventricle with each contraction) and heart rate

Question 7

Which factors influence blood pressure? (Select all that apply)

A. Cardiac output
B. Peripheral vascular resistance
C. Blood volume
D. Stroke volume
E. Pulse pressure

Answer 7

Answers: A. Cardiac output, B. Peripheral vascular resistance, C. Blood volume

Rationale: Blood pressure is influenced by cardiac output, blood volume, and peripheral vascular resistance, as these factors affect the flow of blood through the vascular system​

Question 8

A nurse is assessing a patient for ischemic pain. Which of the following is most commonly associated with ischemia?

A. Pain that increases with rest
B. Pain that decreases with movement
C. Pain that worsens with exercise or activity
D. Pain that radiates down both legs

Answer 8

Answer: C. Pain that worsens with exercise or activity

Rationale: Ischemic pain often increases with physical activity because the demand for oxygen exceeds the supply provided to the tissues

Question 9

The pulse of a healthy adult should fall within which expected reference range?

A. 50 to 90 beats per minute
B. 60 to 100 beats per minute
C. 70 to 120 beats per minute
D. 80 to 130 beats per minute

Answer 9

Answer: B. 60 to 100 beats per minute

Rationale: The expected pulse rate for a healthy adult is between 60 to 100 beats per minute, as this is considered the normal range

Question 10

An apical pulse is best auscultated at the 2nd intercostal space on the left midclavicular line for adults.

Answer 10

Answer: False

Rationale: The apical pulse is best auscultated at the 5th intercostal space on the left midclavicular line for adults

Question 11

A patient with bilateral lower extremity edema is likely to have which condition?

A. Arterial blockage
B. Heart failure
C. Peripheral vascular disease
D. Pulmonary embolism

Answer 11

Answer: B. Heart failure

Rationale: Bilateral lower extremity edema is commonly associated with heart failure, where the heart cannot effectively pump blood, leading to fluid accumulation​

Question 12

Which of the following are signs of inadequate peripheral perfusion? (Select all that apply)

A. Cool extremities
B. Cyanosis
C. Bounding pulses
D. Prolonged capillary refill
E. Jugular vein distention

Answer 12

Answers: A. Cool extremities, B. Cyanosis, D. Prolonged capillary refill

Rationale: Inadequate peripheral perfusion leads to symptoms such as cool extremities, cyanosis (bluish discoloration), and prolonged capillary refill time. Jugular vein distention is a sign of central perfusion issues

Question 13

Which of the following pulses is located behind the knee?

A. Popliteal
B. Dorsalis pedis
C. Posterior tibial
D. Femoral

Answer 13

Answer: A. Popliteal

Rationale: The popliteal pulse is located behind the knee in the popliteal fossa​

Question 14

A nurse notes a patient has a 3+ pulse. How should this pulse be described?

A. Absent
B. Normal
C. Weak
D. Increased or strong

Answer 14

Answer: D. Increased or strong

Rationale: A 3+ pulse is described as increased or strong, whereas 2+ is normal, 1+ is weak, and 0 is absent

Question 15

Clubbing of the fingernails can indicate chronic hypoxia.

Answer 15

Answer: True

Rationale: Clubbing of the fingernails is a sign of chronic hypoxia, often seen in patients with long-standing respiratory or cardiovascular conditions

Question 16

A nurse observes that a patient’s jugular veins are distended while the patient is sitting at a 45-degree angle. What might this indicate?

A. Hypovolemia
B. Right-sided heart failure
C. Peripheral vascular disease
D. Aortic stenosis

Answer 16

Answer: B. Right-sided heart failure

Rationale: Jugular vein distention (JVD) is a sign of right-sided heart failure, where the heart cannot efficiently pump blood, leading to fluid backup​

Question 17

Capillary refill time (CRT) longer than 3 seconds in an adult may indicate:

A. Adequate perfusion
B. Dehydration
C. Impaired circulation
D. Hypothermia

Answer 17

Answer: C. Impaired circulation

Rationale: A capillary refill time longer than 3 seconds typically indicates impaired circulation and inadequate perfusion

Question 18

Which of the following best describes a patient with an apical pulse of 5th intercostal space, left midclavicular line?

A. The pulse is within normal limits
B. The patient has a displaced apical pulse
C. The patient’s apical pulse is inaudible
D. The patient has a strong radial pulse

Answer 18

Answer: A. The pulse is within normal limits

Rationale: In adults, the apical pulse is normally located at the 5th intercostal space at the left midclavicular line​

Question 19

A patient with severe peripheral edema is assessed for the pitting scale. A deep imprint that slowly returns to normal indicates which score?

A. 1+
B. 2+
C. 3+
D. 4+

Answer 19

Answer: D. 4+

Rationale: A 4+ pitting score indicates a deep imprint that is slow to return to normal, which is the most severe form of pitting edema​

Question 20

Which pulse site is located in the groove between the biceps and triceps muscles at the bend of the elbow?

A. Radial
B. Brachial
C. Femoral
D. Posterior tibial

Answer 20

Answer: B. Brachial

Rationale: The brachial pulse is located in the antecubital fossa, between the biceps and triceps muscles

Question 21

Which of the following signs are associated with impaired peripheral perfusion? (Select all that apply)

A. Cool skin
B. Delayed capillary refill
C. Tachycardia
D. Warm extremities
E. Decreased pulse strength

Answer 21

Answers: A. Cool skin, B. Delayed capillary refill, E. Decreased pulse strength

Rationale: Impaired peripheral perfusion often presents with cool skin, delayed capillary refill, and weak pulses. Tachycardia and warm extremities are not typical signs of peripheral perfusion issues

Question 22

Which assessment finding is most concerning in a patient with suspected heart failure?

A. Bounding radial pulse
B. Jugular vein distention
C. Capillary refill of 2 seconds
D. Blood pressure of 118/76 mmHg

Answer 22

Answer: B. Jugular vein distention

Rationale: Jugular vein distention can indicate right-sided heart failure, which is a serious condition that impairs perfusion

Question 23

A nurse is assessing a patient’s apical pulse. Which of the following best describes where the nurse should place the stethoscope for an adult?

A. Second intercostal space, right sternal border
B. Fifth intercostal space, left midclavicular line
C. Fourth intercostal space, left of the sternum
D. Second intercostal space, left sternal border

Answer 23

Answer: B. Fifth intercostal space, left midclavicular line

Rationale: The apical pulse is auscultated at the fifth intercostal space at the left midclavicular line in adults

Question 24

Diaphoresis in a patient with no apparent cause may indicate a cardiac event.

Answer 24

Answer: True

Rationale: Diaphoresis (sweating) without an obvious cause can be a sign of a cardiac event, such as a myocardial infarction (heart attack

Question 25

Which of the following is the best indicator of adequate cerebral perfusion?

A. Clear lung sounds
B. Stable body temperature
C. Appropriate behavior and orientation
D. Strong peripheral pulses

Answer 25

Answer: C. Appropriate behavior and orientation

Rationale: Appropriate mental status, behavior, and orientation indicate adequate cerebral perfusion

Question 26

Which of the following symptoms might indicate a problem with central perfusion? (Select all that apply)

A. Dyspnea
B. Hypotension
C. Edema in the lower extremities
D. Fainting or dizziness
E. Normal apical pulse

Answer 26

Answers: A. Dyspnea, B. Hypotension, D. Fainting or dizziness

Rationale: Central perfusion problems may present as dyspnea, hypotension, and fainting. Edema is more commonly associated with peripheral perfusion, and a normal apical pulse does not indicate a problem

Question 27

Which grading of pulse indicates a normal pulse?

A. +1
B. +2
C. +3
D. +4

Answer 27

Answer: B. +2

Rationale: A pulse graded as +2 is considered normal. A +1 pulse is weak, while a +3 or +4 pulse is strong or bounding【

Question 28

Skin color changes in the extremities are a reliable indicator of impaired peripheral perfusion.

Answer 28

Answer: True

Rationale: Skin color changes, such as pallor or cyanosis, are important indicators of impaired peripheral perfusion【

Question 29

Which of the following nursing interventions is appropriate for a patient with bilateral edema?

A. Keep the patient in a seated position
B. Elevate the patient’s legs
C. Restrict fluid intake
D. Encourage bed rest

Answer 29

Answer: B. Elevate the patient’s legs

Rationale: Elevating the legs helps reduce edema by promoting venous return to the heart

Question 30

Which of the following are methods used to assess edema? (Select all that apply)

A. Palpating the skin for imprint depth
B. Checking skin temperature around the edema
C. Measuring capillary refill time
D. Assessing pulses above and below the edematous area
E. Auscultating heart sounds

Answer 30

Answers: A. Palpating the skin for imprint depth, B. Checking skin temperature around the edema, D. Assessing pulses above and below the edematous area

Rationale: Edema is assessed by palpating for imprint depth, checking skin temperature, and assessing pulse strength in the affected area