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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

A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings concerning the abdomen would include:

Correct Answer: C

Rationale: A rigid, boardlike abdomen is an assessment finding indicative of placenta abruptio. A cause of postbirth hemorrhage is uterine atony. With placenta previa, uterine tone is within normal range. The placenta is located directly over the cervical os in complete previa. Blood will escape through the os, resulting in the uterus and abdomen remaining soft and relaxed. In placenta abruptio, hypertonicity of the uterus is caused by the entrapment of blood between the placenta and uterine wall, a retroplacental bleed. This does not exist in placenta previa.

Question 3 of 5

The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client's chief complaint?

Correct Answer: D

Rationale: (A, B,
C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.

Question 4 of 5

The best size cathlon for administration of a blood transfusion to a six-year-old is:

Correct Answer: D

Rationale: A 20-gauge catheter is appropriate for blood transfusions in a six-year-old balancing adequate flow rate and minimal vessel trauma. Smaller gauges (22) may be too small and larger gauges (18 19) are more invasive than necessary.

Question 5 of 5

The nurse is caring for a client with a diagnosis of gestational diabetes. Which symptom is most likely to be present?

Correct Answer: C

Rationale: Gestational diabetes causes maternal polyuria (from hyperglycemia) and fetal macrosomia (from fetal hyperinsulinemia). Both are common symptoms affecting mother and fetus.

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