The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?

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Question 1 of 5

The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?

Correct Answer: C

Rationale: Ascites results from increased portal pressure in liver disease.

Question 2 of 5

While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?

Correct Answer: A

Rationale: Jaundice within 24-48 hours suggests hemolytic disease from Rh incompatibility, requiring urgent action.

Question 3 of 5

During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?

Correct Answer: D

Rationale: Reduced chest expansion suggests worsening respiratory distress, critical in Legionnaire's.

Question 4 of 5

On admission to the hospital a client with an acute asthma episode has intermittent nonproductive coughing and a pulse oximeter reading of 88%. The client states, 'I feel like this is going to be a bad time this admission. I wish I would not have gone into that bar with all those people who smoke last night.' Which nursing diagnoses would be most important for this client?

Correct Answer: D

Rationale: Pulse oximetry of 88% indicates impaired gas exchange, the most urgent issue.

Question 5 of 5

A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to

Correct Answer: A

Rationale: Sitz baths reduce pain and inflammation from HSV lesions.

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