Free NCLEX RN Practice Test Practice Question
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:
Correct Answer: B
Rationale: A PAWP of 14 mmHg indicates potential fluid overload or left ventricular dysfunction, which can lead to pulmonary congestion. Therefore, assessing for rales on chest auscultation is crucial, as these may indicate fluid accumulation in the lungs.
Option A, a drop in blood pressure, may occur in various conditions but is not directly indicated by the PAWP reading alone. Option C, complaints of chest pain, is nonspecific and not directly related to PAWP changes. Option D, dry mucous membranes, typically suggests dehydration rather than fluid overload, making it less relevant in this context.
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