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
Fever is not a typical symptom of osteoarthritis of the knee. Osteoarthritis is a degenerative joint disease that causes pain and stiffness, but it does not typically cause systemic symptoms like fever.
Choice B rationale
This is the correct answer. Crepitus, which is a grating or crackling sound or sensation, can be a symptom of osteoarthritis of the knee. It is caused by the rubbing of bone on bone due to the loss of protective cartilage in the joint.
Choice C rationale
Malaise, or a general feeling of discomfort or illness, is not a specific symptom of osteoarthritis of the knee. While osteoarthritis can cause discomfort and limit activity, it does not typically cause generalized malaise.
Choice D rationale
Weakness can occur in the muscles around an affected joint due to lack of use or muscle atrophy, but it is not a primary symptom of osteoarthritis of the knee

A. Increase the client’s sodium intake. B. Increase the client’s saturated fat intake. C. Decrease the client’s fluid intake. D. Decrease the client’s carbohydrate intake.

Correct Answer is C

Explanation

Choice A rationale
Increasing sodium intake is not recommended for a client with cirrhosis and ascites. Sodium can cause fluid retention, which can worsen ascites.
Choice B rationale
Increasing saturated fat intake is not recommended for a client with cirrhosis and ascites. A balanced diet with adequate protein and carbohydrates is recommended.
Choice C rationale
Decreasing fluid intake can be a part of the management plan for a client with cirrhosis and ascites. This can help manage fluid balance and prevent further accumulation of fluid in the abdomen.
Choice D rationale
Decreasing carbohydrate intake is not typically recommended for a client with cirrhosis and ascites. Carbohydrates provide a source of energy that is necessary for the body’s functions.

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Naxlex Comprehensive Predictor Exams

A nurse is performing an assessment on a patient who has osteoarthritis of the knee. Which of the following assessment findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is C

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?

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 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 evaluating a client who is at risk for deep-vein thrombosis (DVT). Which of the following symptoms is an indication of DVT?

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

What effect does chronic exposure to ultraviolet (UV) rays have on the skin that increases the risk for skin cancer?

A nurse is caring for four hospitalized patients. Which of the following patients should the nurse identify as being at risk for fluid volume deficit?