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 B

Explanation

Choice A rationale
Donating blood after completing the medication regimen is not typically recommended for patients with hepatitis B. Hepatitis B is a bloodborne virus, and individuals with the virus should not donate blood.
Choice B rationale
Resting frequently throughout the day is a key part of self-management for patients with hepatitis B. Rest can help the body recover and fight off the virus.
Choice C rationale

Taking acetaminophen every 4 hours for discomfort is not typically recommended for patients with hepatitis B. Overuse of acetaminophen can lead to liver damage, which can be particularly harmful for individuals with liver diseases like hepatitis B56.
Choice D rationale
Consuming a high-protein diet is not typically recommended for patients with hepatitis B. A balanced diet is important for overall health, but there are no specific dietary recommendations for hepatitis B56.

A. Avoid serving raw foods. B. Wear barrier protection during vaginal intercourse. C. Avoid eating at fast food restaurants. D. Practice effective hand hygiene.

Correct Answer is ["A","D"]

Explanation

Choice A rationale
Hepatitis A is a highly contagious virus that spreads through person-to-person contact or consuming contaminated food or drink. The virus can contaminate food during growing, harvesting, processing, handling, and even after cooking. Therefore, avoiding serving raw foods can help prevent the spread of the virus.
Choice B rationale

Hepatitis A is not typically spread through sexual intercourse. It is primarily spread through the fecal-oral route, either by person-to-person contact or consumption of contaminated food or water. Therefore, wearing barrier protection during vaginal intercourse is not a primary prevention strategy for Hepatitis A.
Choice C rationale
While it’s possible to contract Hepatitis A from food prepared at any location, including fast food restaurants, the risk is not specifically associated with these establishments. The key is whether the food is contaminated with the virus, which can occur in any setting if food is handled by someone infected with Hepatitis A who doesn’t properly wash their hands after using the toilet.
Choice D rationale
Practicing effective hand hygiene, including thoroughly washing hands after using the bathroom, changing diapers, and before preparing or eating food, is a primary prevention strategy for Hepatitis A1. The virus is spread in part by the fecal-oral route, so good hand hygiene can help prevent ingestion of the virus.

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a patient with hepatitis B about self-management. Which instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is educating a client who has hepatitis A on how to prevent the spread of the virus. Which of the following strategies should the nurse include in the teaching?

Correct Answer is ["A","D"]

Explanation

A nurse is preparing a care plan for a patient who is about to receive a transfusion of packed red blood cells. What should be the maximum duration for the total infusion time?

A nurse is assisting a patient with hypothyroidism in meal planning. Which foods should the nurse suggest the patient add to their diet?

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

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?

A nurse is educating a patient who has a history of ulcerative colitis and has recently been diagnosed with anemia. Which of the following symptoms of colitis should the nurse identify as a contributing factor to the development of anemia?

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 teaching a patient who has a new diagnosis of hyperparathyroidism. The nurse should include in the teaching that the patient is at risk for which of the following complications?