The nurse is caring for a client.

For each assessment finding, click to specify if the assessment finding is consistent with pulmonary embolism, pneumonia, or pneumothorax. Each finding may support more than one disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Heart sounds

Respiratory pattern

Temperature

Lung sounds

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B,C"},"C":{"answers":"B"},"D":{"answers":"A,B"}}

Rationale for correct choices

• Heart sounds: The presence of S3 and S4 heart sounds may indicate right ventricular strain or acute heart failure, which can occur secondary to a massive pulmonary embolism. This finding aligns with increased cardiac workload due to impaired pulmonary circulation. Heart sounds are not typically altered in pneumonia or pneumothorax unless severe cardiac compromise occurs.

• Respiratory pattern: Tachypnea and labored breathing can occur in all three conditions. In pulmonary embolism, rapid breathing compensates for hypoxemia. In pneumonia, increased respiratory rate results from impaired gas exchange and inflammation. In pneumothorax, rapid breathing occurs due to decreased lung expansion and oxygenation.

• Temperature: Fever (38.9° C/102° F) suggests an infectious process, consistent with pneumonia. Pulmonary embolism and pneumothorax typically do not present with elevated temperature unless secondary infection or inflammatory response is present.

• Lung sounds: Bilateral crackles indicate fluid or exudate in the alveoli. In pneumonia, crackles result from consolidation and inflammation. In pulmonary embolism, crackles may reflect pulmonary infarction or edema from right-sided heart strain. Pneumothorax generally produces absent or decreased breath sounds rather than crackles, so crackles are less indicative.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Administer calcium gluconate for urine output less than 50 mL/hr: Calcium gluconate is given to treat magnesium sulfate toxicity, which is indicated by absent deep tendon reflexes, respiratory depression, or high serum magnesium levels. Low urine output requires monitoring but does not automatically warrant calcium gluconate administration.

B. Check deep tendon reflexes every 8 hr: Deep tendon reflexes should be assessed frequently during magnesium sulfate therapy, usually every 1–2 hours, to detect early signs of toxicity. Checking only every 8 hours is insufficient for safe monitoring.

C. Administer one dose of betamethasone now and repeat in 24 hr: Betamethasone is given to accelerate fetal lung maturity in preterm gestation, which is critical at 31 weeks. Administering the two-dose course as prescribed helps reduce neonatal respiratory complications, making this a priority intervention alongside magnesium sulfate therapy.

D. Limit IV intake to no more than 200 mL/hr: Monitoring and limiting IV fluids helps prevent fluid overload and pulmonary edema in preeclamptic clients, but ensuring fetal lung maturity with betamethasone takes priority at this gestational age in case of an early delivery.

A. Recurrent UTI B. Family history of type 2 diabetes mellitus C. Heart rate is consistently between 55/min and 58/min D. Reports decrease in urination frequency

Correct Answer is A

Explanation

A. Recurrent UTI: Frequent urinary tract infections can be a sign of gestational diabetes mellitus (GDM) because hyperglycemia creates an environment conducive to bacterial growth. Recurrent infections may indicate impaired glucose regulation and warrant further screening for GDM.

B. Family history of type 2 diabetes mellitus: While a family history increases the client’s risk for developing GDM, it is not a direct indicator that the client currently has gestational diabetes. It is considered a risk factor rather than a presenting finding.

C. Heart rate is consistently between 55/min and 58/min: A slightly lower maternal heart rate is not indicative of gestational diabetes. Maternal bradycardia in this range is usually not related to glucose metabolism and may be influenced by other factors such as fitness level or medication use.

D. Reports decrease in urination frequency: Gestational diabetes typically causes polyuria rather than decreased urination. Reduced urination is not a characteristic finding associated with GDM and may suggest other renal or hydration issues instead.

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is at 31 weeks of gestation and has preeclampsia with severe features. The client has a new prescription for magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse in a prenatal clinic is caring for a client who is at 24 weeks of gestation. Which of the following findings is a potential indication the client has gestational diabetes mellitus?

Correct Answer is A

Explanation

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