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 ["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.

A. Free T4. B. Serum T3. C. Thyroid stimulating hormone (TSH). D. Serum calcium.

Correct Answer is C

Explanation

Choice A rationale
Free T4 levels are typically low in primary hypothyroidism, not elevated.

Choice B rationale
Serum T3 levels are also typically low in primary hypothyroidism.
Choice C rationale
In primary hypothyroidism, the thyroid gland is not producing enough thyroid hormone, leading to an elevated TSH level as the pituitary gland tries to stimulate more hormone production.
Choice D rationale
Serum calcium levels are not directly affected by primary hypothyroidism.

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Naxlex Comprehensive Predictor Exams

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 in a clinic is reviewing the laboratory values of a patient who has primary hypothyroidism. The nurse should anticipate an elevation in which of the following laboratory values?

Correct Answer is C

Explanation

The nurse is caring for a patient with active hepatitis C and recalls that the disease is spread by which route?

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 educating a patient who has been prescribed a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following reasons for the use of the nasogastric tube should the nurse include in the teaching?

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

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A nurse is attending to a client who has just been admitted due to an acute exacerbation of ulcerative colitis. What should be the nurse’s initial course of action?

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