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 A

Explanation

A. Prime the tubing with 0.9% sodium chloride: Blood products must be administered with 0.9% sodium chloride to prevent hemolysis. Priming the tubing with saline ensures compatibility and maintains patency, allowing safe and effective transfusion without compromising the integrity of red blood cells.

B. Attach a single-line administration set: Blood transfusions require a specialized Y-type or filtered tubing to reduce the risk of clots, debris, and air embolism. Using a single-line set without a filter could allow microaggregates to enter the circulation.

C. Use tubing that does not have a filter in the drip chamber: A filter is essential for removing clots, debris, and cellular aggregates from the blood product. Administering blood without a filter increases the risk of complications such as emboli and febrile reactions.

D. Use an IV catheter that is at least 24-gauge: A 24-gauge catheter is too small for safe transfusion of blood products. A larger-bore catheter, typically 18–20 gauge, is recommended to allow adequate flow and prevent hemolysis or catheter rupture during transfusion.

A. A client who is bedridden and wears a hearing aid. B. A client who is ambulatory and receiving oxygen. C. A client who has a fracture and is in balance suspension traction. D. A client who uses a wheelchair and is confused.

Correct Answer is B

Explanation

A. A client who is bedridden and wears a hearing aid: While immobile clients require assistance during evacuation, hearing loss does not inherently increase immediate risk in a fire scenario. Evacuation priority is based on threat to life, not sensory impairment alone.

B. A client who is ambulatory and receiving oxygen: Oxygen therapy increases the risk of rapid combustion in a fire. An ambulatory client on supplemental oxygen poses the greatest immediate danger and should be evacuated first to prevent serious injury or death from fire or explosion.

C. A client who has a fracture and is in balanced suspension traction: Clients in traction are immobile and require additional assistance for safe evacuation, but they do not present the highest immediate risk compared with a client on oxygen near a fire.

D. A client who uses a wheelchair and is confused: Confusion can complicate evacuation and requires supervision, but oxygen exposure in a fire presents a more imminent threat, making this client a lower priority than the client receiving oxygen.

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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 _____ .

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?

Correct Answer is B

Explanation

A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?

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The nurse is continuing to care for the client. The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

The nurse continues to care for the client. Select 1 condition and 1 client finding to fill in each blank in the following sentence. The client is most likely experiencing _____ as evidenced by the client's _____ .

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A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take when communicating with the client?

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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
_
.