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
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Rationale for correct choices
• Spontaneous abortion: The client is presenting at 10 weeks gestation with moderate, bright red vaginal bleeding and a history of risk factors including type 1 diabetes mellitus and recurrent infections. The open cervix on examination indicates that the pregnancy may not be viable and suggests impending or ongoing miscarriage.
• Cervical dilation: Cervical dilation is a key clinical sign of spontaneous abortion, as it indicates that the body is preparing to expel the pregnancy. The presence of an open cervix in conjunction with vaginal bleeding and cramping directly supports the risk for miscarriage. Monitoring cervical changes helps the healthcare team assess the progression and urgency of intervention.
Rationale for incorrect choices
• Molar pregnancy: Molar pregnancy typically presents with markedly elevated hCG levels, larger-than-expected uterine size, and absence of a viable embryo. Although the client has an elevated hCG, the level is not excessively high, and there is no indication of vesicular tissue or characteristic ultrasound findings, making molar pregnancy unlikely.
• Ectopic pregnancy: Ectopic pregnancy generally presents with unilateral abdominal pain, shoulder pain, and sometimes hypotension or signs of internal bleeding. The client’s bleeding is bright red, moderate, and accompanied by cervical dilation, which is not typical for an ectopic pregnancy. No abdominal mass or unilateral tenderness is reported, reducing the likelihood of this diagnosis.
• Lower abdominal cramping: While cramping is a symptom associated with miscarriage, it alone is not sufficient evidence to determine the risk for spontaneous abortion. Cervical dilation is a more definitive clinical sign indicating that the miscarriage may be occurring or imminent.
• hCG levels: The client’s hCG level of 30,000 IU/L is within the expected range for 10 weeks gestation and does not specifically indicate miscarriage. Unlike cervical dilation, hCG levels alone cannot confirm the risk for spontaneous abortion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E","G"]
Explanation
Rationale:
A. Enoxaparin 80 mg subcutaneous twice a day: Enoxaparin is an anticoagulant used for prevention or treatment of thromboembolic events. There is no indication from the client’s current labs, vitals, or diagnostics (D-dimer within normal limits, no evidence of clot) to initiate anticoagulation at this time.
B. Potassium chloride 20 mEq PO twice a day: The client’s potassium level is 3.6 mEq/L, which is at the lower end of the normal range. Supplementation may be warranted, particularly if antihypertensive therapy such as a diuretic is initiated, to prevent hypokalemia and maintain cardiac stability.
C. Ciprofloxacin 750 mg PO twice a day: There is no evidence of bacterial infection in the client’s assessment, labs, or diagnostics. Prescribing an antibiotic is unnecessary and not indicated.
D. Enalapril 5 mg PO daily: The client’s blood pressure is 164/92 mm Hg, which is hypertensive. Enalapril, an ACE inhibitor, is appropriate to manage hypertension, reduce cardiovascular risk, and potentially improve renal outcomes given the family history of renal failure.
E. Rosuvastatin 20 mg PO daily: The client has significantly elevated cholesterol (total cholesterol 280 mg/dL, LDL 220 mg/dL, HDL 20 mg/dL) and triglycerides 220 mg/dL. Initiating a statin is appropriate to reduce cardiovascular risk and manage hyperlipidemia.
F. Digoxin 0.25 mg PO daily: The client does not exhibit heart failure symptoms or arrhythmias that require digoxin at this time. ECG shows only sinus tachycardia without S-T changes, so digoxin is not indicated.
G. Metformin 850 mg PO daily: The client’s glucose is 310 mg/dL and HbA1c is 7%, indicating diabetes mellitus. Initiating metformin is appropriate for glycemic control and to reduce the risk of complications associated with hyperglycemia.
H. Albuterol 2 puffs every 4 to 6 hr as needed: The client’s lungs are clear on auscultation, and there is no active respiratory distress. Albuterol is not indicated for ongoing therapy in this assessment.
Correct Answer is B
Explanation
Rationale:
A. Report the pump has a frayed cord and proceed with the infusion: Using a pump with a frayed cord is unsafe and poses a risk of electrical shock or malfunction. The pump should not be used until it is repaired or replaced, so proceeding with the infusion is inappropriate.
B. Check the expiration date on the safety inspection sticker of the pump: Verifying that the infusion pump has a current safety inspection ensures that the device has been tested and is functioning properly. This action is essential to prevent mechanical failure and maintain patient safety during IV therapy.
C. Obtain a surge protector that can accommodate the pump and several other appliances: Infusion pumps should be plugged directly into a properly grounded outlet to ensure consistent power and prevent electrical hazards. Connecting multiple devices through a surge protector can overload the circuit and compromise pump function.
D. Verify that the extension cord for the pump is ungrounded: Using an ungrounded extension cord increases the risk of electrical shock and device malfunction. Only properly grounded outlets and cords should be used with infusion pumps to maintain safety.
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