A nurse is caring for a client who has an ectopic pregnancy. Which of the following findings should the nurse expect?

Abdominal pain

Hydramnios

Profuse vaginal bleeding

Elevated blood pressure

Answer and Explanation

The Correct Answer is A

Choice A reason: Abdominal pain is a hallmark of ectopic pregnancy, where the embryo implants outside the uterus, often in the fallopian tube. Tissue stretching or rupture causes localized pain, driven by tubal irritation or internal bleeding, requiring urgent evaluation to prevent life-threatening hemorrhage in affected clients.
Choice B reason: Hydramnios, excessive amniotic fluid, occurs in intrauterine pregnancies, not ectopic ones, which lack a uterine gestational sac. Ectopic pregnancies cannot produce amniotic fluid, as implantation occurs outside the uterus, making hydramnios an irrelevant finding in this condition’s pathophysiology.
Choice C reason: Profuse vaginal bleeding is uncommon in ectopic pregnancy, which typically causes spotting or mild bleeding. Heavy bleeding suggests miscarriage or other conditions. Ectopic pregnancies cause internal bleeding, leading to abdominal pain, not profuse vaginal hemorrhage, a key diagnostic distinction.
Choice D reason: Elevated blood pressure is not typical in ectopic pregnancy unless complicated by pain-induced stress or shock. Internal bleeding from ectopic rupture often lowers blood pressure due to hypovolemia, making hypertension an unlikely finding compared to the expected abdominal pain presentation.

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Correct Answer is B

Explanation

Choice A reason: Removing a thermometer for use on another client risks cross-contamination, as C. difficile spores are highly transmissible. Dedicated equipment is required to prevent spread, so this action is incorrect and violates infection control protocols.
Choice B reason: Wearing a gown during care prevents C. difficile spore transmission via contact, a key precaution for this infection. This aligns with CDC contact isolation guidelines, protecting staff and other patients, making it the correct action.
Choice C reason: Washing hands with alcohol-based cleaner is ineffective against C. difficile spores, which require soap and water to physically remove them. This action is incorrect and inadequate for infection control in this scenario.
Choice D reason: Wearing an N95 respirator is unnecessary, as C. difficile is not airborne. Contact precautions (gown, gloves) suffice, so this action is incorrect and overprotective, wasting resources without addressing the transmission mode.

A. The person holding financial power of attorney will make health care decisions based on the client’s advance directives. B. The client has the right to refuse medical treatment, even if health care providers recommend it. C. If the client’s advance directives are in writing and notarized, the client cannot change it in the future. D. The client’s eldest adult child has the right to change advance directives in an end-of-life situation.

Correct Answer is B

Explanation

Choice A reason: Financial power of attorney manages monetary decisions, not health care, unless specified as a health care surrogate. Advance directives guide health decisions, but this role is distinct, making this statement incorrect under the Patient Self-Determination Act’s provisions.
Choice B reason: The Patient Self-Determination Act ensures clients’ rights to refuse treatment, even against provider recommendations, promoting autonomy through advance directives. This legal protection applies in Medicare/Medicaid facilities, making it the correct principle for end-of-life decision-making in this context.
Choice C reason: Advance directives can be changed by a competent client, even if notarized, as the Act supports ongoing autonomy. Stating they cannot be altered is incorrect, as flexibility is a core feature, making this an inaccurate representation of the law.
Choice D reason: The eldest adult child cannot change advance directives unless designated as a surrogate. The Act prioritizes the client’s documented wishes or appointed decision-maker, not family hierarchy, making this statement incorrect and misaligned with legal requirements.

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A nurse is caring for a client who has an ectopic pregnancy. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who is seeking information about end-of-life decisions. According to the Patient Self-Determination Act, which of the following applies to medical decisions that can be made within organizations that receive Medicare and Medicaid reimbursements?

Correct Answer is B

Explanation

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