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Questions 158

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Question 1 of 5

A client with pancreatitis has been transferred to the intensive care unit. The nurse assesses a pulmonary arterial wedge pressure (PAWP) of 14 mmHg. Based on this finding, the nurse would want to further assess for what additional correlating wedge pressure data?

Correct Answer: B

Rationale: PAWP of 14 mmHg is elevated, suggesting left ventricular overload. Rales (
B) indicate pulmonary edema, correlating with high PAWP. BP drop (
A), fever (
C), and dry membranes (
D) are unrelated.

Question 2 of 5

The registered nurse is making shift assignments. Which client should be assigned to the licensed practical nurse (LPN)?

Correct Answer: A

Rationale: A diabetic with a foot ulcer is stable and suitable for an LPN, who can perform wound care and monitoring. Heparin infusion (
B), tracheostomy weaning (
C), and T-tube management (
D) require RN-level skills due to complexity and risk.

Question 3 of 5

The client is admitted with a diagnosis of molar pregnancy. Which symptom is most likely to be present?

Correct Answer: A

Rationale: Molar pregnancy (hydatidiform mole) often causes severe nausea and vomiting due to high levels of human chorionic gonadotropin (hCG). The uterus is typically larger than expected and fetal heart tones are absent as there is no viable fetus.

Question 4 of 5

A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:

Correct Answer: A

Rationale: The ischial spines mark the narrowest diameter of the pelvis, critical for assessing fetal descent during labor.

Question 5 of 5

A male client tells his nurse that he has had an ulcer in the past and is afraid it is 'flaring up again.' The nurse begins to ask him specific questions about his symptoms. The nurse knows that a symptom that might indicate a serious complication of an ulcer is:

Correct Answer: C

Rationale: Clients with ulcers generally experience abdominal pain. It is common to have pain in the early morning hours with an ulcer. Constipation is not a symptom associated with ulcers and would indicate a need to look at other factors. Melena is blood in the stools. This could indicate a slow bleeding ulcer, which could result in significant amounts of blood loss over time. Nausea and vomiting may be present as a result of the ulcer, especially if it is a gastric ulcer. This does not indicate an immediate life-threatening complication.

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