A nurse is assessing an elderly patient who has just been admitted to the medical-surgical unit with significant abdominal ascites.
The patient is alert and oriented, walks independently at home, and usually uses a cane but forgot to bring it to the hospital.Which measures should the nurse prioritize?

Implementing a bleeding precaution protocol

Implementing a skin safety protocol

Implementing a sodium restriction diet

Implementing a fall risk protocol

Answer and Explanation

The Correct Answer is D

Choice A rationale
While bleeding precautions are important in certain conditions, they may not be the priority for a patient with significant abdominal ascites. Ascites, the accumulation of fluid in the peritoneal cavity, is often caused by liver disease such as cirrhosis.
Choice B rationale
Skin safety protocols are important for all patients, but they may not be the priority in this case. Ascites can cause discomfort and other complications, but it does not directly cause skin problems.
Choice C rationale
A sodium restriction diet can be beneficial for patients with ascites, as it can help reduce fluid accumulation. However, this measure may not be the priority in this case.
Choice D rationale
Implementing a fall risk protocol should be prioritized. The patient’s significant abdominal ascites could affect their balance and mobility, increasing their risk of falls. Furthermore, the patient usually uses a cane for support but forgot to bring it to the hospital, further increasing their fall risk.

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Correct Answer is C

Explanation

Choice A rationale
While performing self-examinations for breast cancer can help in early detection of the disease, it does not provide information about a person’s genetic risk for developing breast cancer.
Choice B rationale
Having a suspicious mammogram could indicate the presence of breast cancer or other abnormalities, but it does not provide information about a person’s genetic risk for developing the disease.
Choice C rationale
Being aware of one’s BRCA (breast cancer gene) status is directly related to understanding their genetic risk for breast cancer. Mutations in the BRCA1 and BRCA2 genes significantly increase the risk of developing breast cancer.

Choice D rationale
Noticing dimpling during a breast self-exam could be a sign of breast cancer, but it does not provide information about a person’s genetic risk for developing the disease.

A. The client will increase calorie intake by 200 cal per day. B. The client will list foods that are high in calcium, which should be avoided. C. The client will replace cigarettes with smokeless tobacco products. D. The client will walk for 30 min 5 days a week.

Correct Answer is D

Explanation

Choice A rationale
Increasing calorie intake by 200 cal per day may not be beneficial for this client. The client has a BMI of 26, which is considered overweight. Therefore, a goal to increase calorie intake may contribute to further weight gain.
Choice B rationale
Listing foods that are high in calcium which should be avoided is not a relevant goal for this client. Calcium is an essential nutrient and there is no indication that the client needs to avoid it.
Choice C rationale
Replacing cigarettes with smokeless tobacco products is not a healthy goal. Smokeless tobacco products also contain harmful chemicals and can lead to health problems.
Choice D rationale

Walking for 30 min 5 days a week is a beneficial goal for this client. Regular physical activity can help manage weight, lower blood pressure, and reduce the risk of heart disease. It can also help the client quit smoking by reducing cravings and withdrawal symptoms.

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Naxlex Comprehensive Predictor Exams

Which of the following assessments would be most useful in determining a patient’s genetic risk for breast cancer?

Correct Answer is C

Explanation

A nurse is setting health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should be included in the plan?

Correct Answer is D

Explanation

A nurse is caring for a client who is experiencing chills and back pain during a blood transfusion. What should be the nurse’s priority action?

The nurse is assessing a patient with irritable bowel syndrome (IBS). The nurse recalls which non-gastrointestinal symptom is associated with the diagnosis.

A nurse is caring for a patient who continues to have issues with GERD (gastroesophageal reflux disease). Which of the following statements provides the best preventative health care education for this patient?

A nurse is caring for a client who is receiving one unit of packed red blood cells (RBCs) due to intraoperative blood loss. The client reports chills and back pain, and their blood pressure is 80/64 mm Hg. What should be the nurse’s first action?

A nurse is caring for a patient who has rheumatoid arthritis and tells the nurse that she wears a copper bracelet to help her feel better. Which of the following responses should the nurse make?

A nurse is providing discharge education to a patient who recently experienced an acute gout attack. Which patient statement indicates they have understood the treatment plan?

A nurse is caring for an elderly patient with significant ascites due to end-stage liver disease. Which of the following precautions should the nurse include in the patient’s care plan?

A nurse is caring for a patient in the primary care office who states, “I think I have been experiencing symptoms of reflux.”. Which of the following manifestations should the nurse anticipate for a patient who has GERD?