A client with recurrent ascites from cirrhosis describes having no appetite or energy to the home health practical nurse (PN). What diet suggestions should the PN provide for the client? Select all that apply.

Limit servings of fresh fruits and vegetables.

Consume concentrated sweets to boost energy.

Try to eat at least six small meals daily.

Choose small helpings from lean protein sources.

Avoid adding salt to foods when cooking or at the table.

Answer and Explanation

Correct Answer : C,D,E

A. Limiting fresh fruits and vegetables is not necessary for clients with ascites due to cirrhosis unless they are causing specific issues like bloating or discomfort. Fresh fruits and vegetables are generally healthy and can be part of a balanced diet unless restricted for other reasons.
B. Consuming concentrated sweets to boost energy is not a recommended dietary strategy for managing ascites or cirrhosis. This approach may lead to excessive calorie intake without addressing the nutritional needs for a balanced diet.
C. Eating six small meals daily can help manage low appetite and energy levels by providing consistent nutrition throughout the day. Small, frequent meals are easier to consume and can help maintain adequate caloric intake for individuals with low appetite.
D. Choosing small helpings from lean protein sources is a good suggestion for managing ascites and cirrhosis. Lean proteins are important for maintaining muscle mass and supporting overall health without exacerbating liver disease.
E. Avoiding adding salt to foods helps manage fluid retention associated with ascites. Reducing sodium intake is crucial for managing ascites and preventing further fluid accumulation.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","E","G"]

Explanation

A. Respiratory rate 18 breaths/minute
The respiratory rate is within the normal range for an adult (12-20 breaths/minute). No immediate follow-up is required for this vital sign.
B. Heart rate 101 beats/minute
An elevated heart rate (tachycardia) can indicate several issues, including fever, infection, or pain. In the context of a surgical site infection and elevated temperature, tachycardia is a sign of systemic response and needs to be evaluated further to determine the cause and appropriate intervention.
C. Capillary refill 2 seconds
Capillary refill time of 2 seconds is within the normal range (≤ 2 seconds) and indicates adequate perfusion. No immediate follow-up is needed.
D. Breath sounds clear and equal bilaterally
This finding indicates no acute respiratory issues. No immediate follow-up is necessary based on this assessment.
E. Turban dressing is saturated with serosanguinous drainage
Saturation of the dressing with serosanguinous drainage indicates a significant amount of wound drainage, which could suggest worsening of the infection or a new complication. This finding requires immediate follow-up to assess the wound and determine if additional interventions or changes in treatment are necessary.
F. Blood pressure 140/84 mm Hg
While slightly elevated, this blood pressure reading is not excessively abnormal and does not require immediate follow-up in the absence of other symptoms. Monitoring is required but not urgent.
G. Temperature 101.9° F (38.8° C)
An elevated temperature indicates a fever, which is a sign of infection. Given the positive MRSA culture and the need for infection control, this temperature warrants immediate follow-up to assess for worsening infection and determine the need for antipyretics or antibiotics.
H. Client is awake and alert
Being awake and alert is a positive finding and does not require immediate follow-up

A. A preschooler who had an emergency appendectomy for appendicitis. B. An adult with osteomyelitis who had a necrotic bone fragment removed in the foot. C. A post-menopausal client with breast cancer who had a right breast lumpectomy. D. An adolescent with type 1 diabetes (DM) who had an open cholecystectomy.

Correct Answer is A

Explanation

A. A preschooler who had an emergency appendectomy should be checked first. Children are at higher risk for complications due to their size and the stress of emergency surgery, so close monitoring is essential.
B. An adult with osteomyelitis post-surgery is important to monitor but is generally at lower immediate risk compared to a young child following emergency surgery.
C. A post-menopausal client with breast cancer who had a lumpectomy is also a priority, but the immediate postoperative period for a child in emergency surgery takes precedence.
D. An adolescent with type 1 diabetes who had cholecystectomy requires careful monitoring, but the child’s higher risk in the immediate postoperative phase makes them the priority.

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A client with recurrent ascites from cirrhosis describes having no appetite or energy to the home health practical nurse (PN). What diet suggestions should the PN provide for the client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The practical nurse (PN) performs a focused assessment and documents it in the computer. Select what items require immediate follow-up by the PN. Select all that apply.

Correct Answer is ["B","E","G"]

Explanation

The practical nurse (PN) is planning evening shift rounds for a group of postoperative clients who all had surgery earlier that day. Which client should the PN check first?

Correct Answer is A

Explanation

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In providing care for a client with a nasogastric tube (NGT) connected to intermittent suction, which task can be assigned to the unlicensed assistive personnel (UAP)?

A client with Parkinson's disease is experiencing decreased postural reflexes, rigidity, retropulsive gait, and shuffling. Which intervention is most important for the practical nurse (PN) to implement?

During a nonstress test of a 38-week client, the practical nurse (PN) observes the fetal heart rate increases 15 beats above baseline lasting 10 seconds twice during a 20-minute tracing. Which finding should the PN document in the electronic medical record?

The practical nurse (PN) is observing a newly hired unlicensed assistive personnel (UAP) bathing a client who has type 2 diabetes mellitus (DM). The UAP places the client's feet in a wash basin filled with warm soapy water to soak. Which action should the PN take?