A nurse is preparing a teaching plan for a newly married female client with a cervical spinal cord injury who would like to have children someday. The client does not want to become pregnant at this time. What information would be important for the nurse to include? Select all that apply.

Explain that is not possible for her to become pregnant

Suggest she take oral birth control pills

suggest the couple use condoms

Instruct the client's husband how to properly insert a diaphragm

Provide her husband with a vasectomy referral

Answer and Explanation

Correct Answer : B,C,D

Rationale:

A. A cervical spinal cord injury does not automatically prevent pregnancy. Fertility may be reduced depending on the injury, but many women with spinal cord injuries can conceive. Telling the client she cannot become pregnant is inaccurate and may lead to unsafe assumptions about contraception.

B. Oral contraceptives are a reversible, effective method to prevent pregnancy. The nurse should provide teaching on proper use, potential side effects, and any contraindications, such as increased risk of blood clots in clients with reduced mobility.

C. Condoms are a non-hormonal contraceptive method that also protect against sexually transmitted infections. They are an important option for clients who cannot or choose not to use hormonal contraception.

D. Barrier methods like a diaphragm are effective if used correctly. Teaching the partner proper insertion ensures correct use and safety, which is particularly important if the client has limited mobility.

E. Vasectomy is a permanent contraceptive method, which is inappropriate for a couple who desires children in the future. Suggesting a vasectomy would contradict the client’s goal of having children someday.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. After a liver biopsy, the risk of complications such as hemorrhage is highest in the first few hours. Therefore, vital signs should be assessed every 15 minutes for the first hour, every 30 minutes for the second hour, and then hourly if stable. Waiting an entire hour between assessments is inadequate and could delay detection of hypotension, tachycardia, or other early signs of internal bleeding.

B. After a liver biopsy, it is standard practice to position the client on their right side with a pillow or small cushion under the puncture site. This applies direct pressure to the liver to help achieve hemostasis, reducing the risk of post-procedural bleeding or hematoma formation. Maintaining this position for at least 2 to 4 hours is recommended. This action reflects a clear understanding of post-procedural care and the priority of protecting the biopsy site.

C. Clients are typically instructed to remain on bed rest for 2 to 6 hours, depending on provider protocol. Early ambulation increases intra-abdominal pressure and raises the risk of bleeding or dislodging the clot at the biopsy site, potentially leading to hemorrhage, hypotension, and pain.

D. While coughing and deep breathing are important for preventing pulmonary complications like atelectasis, they should be avoided immediately after a liver biopsy. Forceful coughing or deep breathing increases intra-abdominal pressure, which can disrupt the liver puncture site, cause bleeding, and lead to pain or hematoma formation.

A. PaO2 of 46 mm Hg (80-100 mm Hg) B. lack of adventitious lung sounds C. respirations of 20 breaths/min (12-20 breaths/min) D. oxygen saturation of 95% on room air (95-100%)

Correct Answer is A

Explanation

Rationale:

A. A PaO₂ of 46 mm Hg is critically low and indicates severe hypoxemia. Normal PaO₂ ranges from 80–100 mm Hg. A value of 46 mm Hg reflects significant impairment in oxygen exchange and can lead to tissue hypoxia, organ failure, and death if not treated immediately. Acute pancreatitis can lead to acute respiratory distress syndrome (ARDS) due to systemic inflammation and capillary leakage in the lungs. According to airway, breathing, and circulation (ABC) priority principles, impaired oxygenation is an immediate life-threatening condition and is the greatest concern.

B. Lack of adventitious lung sounds is not necessarily abnormal. Clear lung sounds can be present even in early respiratory compromise. The absence of crackles, wheezes, or rhonchi does not rule out hypoxemia. Therefore, this finding is not as concerning as a critically low PaO₂.

C. A respiratory rate of 20 breaths per minute is at the upper limit of normal (12–20 breaths/min). While it may suggest mild compensation or anxiety, it is not immediately life-threatening and does not indicate severe respiratory compromise by itself.

D. An oxygen saturation of 95% on room air is within normal limits. Although it should be monitored closely in a client with respiratory distress, this value alone does not indicate acute deterioration.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is preparing a teaching plan for a newly married female client with a cervical spinal cord injury who would like to have children someday. The client does not want to become pregnant at this time. What information would be important for the nurse to include? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for the client following a liver biopsy with the assistance of the student nurse. Which action by the student nurse demonstrates an understanding of the post-procedural care?

Correct Answer is B

Explanation

A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which assessment finding is the greatest concern?

Correct Answer is A

Explanation

While in the emergency department, a client with C8 quadriplegia develops a blood pressure of 80/44 mmHg, pulse of 48 beats per minute, and respiratory rate of 18 breaths per minute. Which condition should the nurse suspect?

A nurse is assisting with field triage following a motor-vehicle crash involving a bus with multiple victims. The nurse assesses a child who has an open fracture of the femur. Which action should the nurse take?

The nurse notes new areas of ecchymosis on the arms and legs of a client with liver cirrhosis. Which laboratory test results should the nurse monitor because of this finding? Select all that apply.

A nurse is preparing a teaching plan for a newly married female client with a cervical spinal cord injury who would like to have children someday. The client does not want to become pregnant at this time. What information would be important for the nurse to include? Select all that apply.

A client dies in the emergency department. The client's mother states that she is overwhelmed and doesn't know how to proceed since she has never had a death in the family before. Which action should the nurse avoid?

The nurse assesses a client who is one day postoperative from Whipple surgery. Which client problem should the nurse prioritize?

The nurse assesses a client with a pleural chest tube inserted to treat a pneumothorax. Which findings require immediate notification to the provider? Select all that apply.

A nurse plans care for a client with a halo fixator. Which intervention should the nurse include in this client's plan of care?