A nurse is caring for a client at the clinic.

Complete the following sentence by using the lists of options.

The client is at risk for
_
as evidenced by
_
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Rationale for correct choices

• Spontaneous abortion: The client is at 10 weeks gestation with vaginal bleeding, abdominal cramping, and an open cervix, which are classic findings associated with spontaneous abortion. The presence of cervical dilation indicates that pregnancy loss is actively occurring or imminent. These findings distinguish spontaneous abortion from other early pregnancy complications.

• Cervical dilation: Cervical dilation during early pregnancy is a key indicator of pregnancy loss. In spontaneous abortion, the cervix opens as products of conception begin to pass. This finding provides objective evidence that the pregnancy is not being maintained.

Rationale for incorrect choices

• Molar pregnancy: Molar pregnancy is associated with excessively high hCG levels, uterine enlargement greater than gestational age, and symptoms such as severe nausea or hyperemesis. The client’s hCG level is appropriate for gestational age and does not suggest trophoblastic overgrowth. Cervical dilation is not a defining feature of molar pregnancy.

• Ectopic pregnancy: Ectopic pregnancy typically presents with unilateral pelvic pain, possible shoulder pain, and often no cervical dilation. Vaginal bleeding may occur, but the cervix usually remains closed. Additionally, ectopic pregnancies often have lower-than-expected hCG levels.

• Lower abdominal cramping: Abdominal cramping is a common symptom in many early pregnancy complications and is not specific to spontaneous abortion. While it supports uterine activity, it does not independently confirm pregnancy loss. Cervical dilation provides stronger diagnostic evidence. Cramping alone is insufficient as the primary indicator.

• hCG levels: The client’s hCG level is within the expected range for 10 weeks gestation. Abnormally high levels would suggest molar pregnancy, while low or slowly rising levels might suggest ectopic pregnancy or nonviable gestation. In this case, hCG does not explain the acute findings.

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Correct Answer is B

Explanation

A. Administer a bronchodilator after the procedure: Bronchodilators are usually administered before postural drainage and percussion to open the airways, enhance mucus clearance, and reduce bronchospasm. Administering afterward would not optimize airway clearance.

B. Perform the procedure prior to meals: Performing postural drainage before meals helps prevent nausea and vomiting, which can occur if the stomach is full. This timing also enhances comfort and safety during chest physiotherapy for children with cystic fibrosis.

C. Perform the procedure twice each day: Children with cystic fibrosis often require more frequent airway clearance, sometimes three to four times daily, depending on clinical status. Limiting it to twice daily may be insufficient to prevent mucus accumulation.

D. Hold hand flat to perform percussions on the child: Percussions should be performed with cupped hands, not flat hands, to create a vibration that loosens mucus in the airways. Flat-hand technique is ineffective and does not facilitate optimal airway clearance.

A. "Limit your fluid intake to 500 milliliters per day." B. "Take your diuretic medication with your evening meal." C. "Plan to urinate every 3 hours while you are awake." D. "Decrease your intake of cranberry juice."

Correct Answer is C

Explanation

A. "Limit your fluid intake to 500 milliliters per day.": Severely restricting fluid intake can lead to dehydration and concentrated urine, which can irritate the bladder and worsen incontinence. Adequate hydration is essential during bladder retraining.

B. "Take your diuretic medication with your evening meal.": Diuretics should generally be taken in the morning to avoid nocturia and sleep disturbances, which could interfere with bladder retraining efforts. Evening dosing may exacerbate incontinence at night.

C. "Plan to urinate every 3 hours while you are awake.": Scheduled voiding is a core strategy in bladder retraining. Urinating at regular intervals, such as every 2–3 hours, helps the bladder gradually increase its capacity and reduces episodes of urge incontinence.

D. "Decrease your intake of cranberry juice.": While certain irritants like caffeine, alcohol, and carbonated beverages should be avoided, cranberry juice is not a primary bladder irritant for most. In fact, it is often encouraged to prevent urinary tract infections (UTIs), which can cause temporary urge incontinence.

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Body System	Common Adverse Effects
Head, eyes, ears, nose, and throat (HEENT)	_____
Cardiovascular	_____
Genitourinary	_____
Gastrointestinal	_____

A nurse is caring for a client at the clinic. Complete the following sentence by using the lists of options. The client is at risk for _____ as evidenced by _____ .

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instructions should the nurse give the client?

Correct Answer is C

Explanation

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A nurse is preparing to teach the parents of a child who has cystic fibrosis. Which of the following instructions should the nurse plan to include?

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A nurse is caring for a client at the clinic.

Complete the following sentence by using the lists of options.

The client is at risk for
_
as evidenced by
_
.