The nurse is assessing the client's intake and output values for the shift (see chart below).

Intake for the shift

250mL Water

120mL Coffee

500mL Intravenous fluid

135 mL Orange Juice

120 mL Ice Cream

120 mL Jello

Output for the shift

545mL Urine

53mL Wound Drainage

200mL Emesis

375mL Urine

200mL Urine

75mL Loose Stool

480mL Urine

Based on these intake and output findings, what is the priority assessment by the nurse?

Palpate for pitting edema.

Assess for oral temperature.

Inspect the oral mucosa.

Auscultate adventitious lung sounds.

Answer and Explanation

The Correct Answer is C

A. Palpating for pitting edema assesses for fluid overload, but this client is more likely experiencing fluid deficit rather than retention.
B. Assessing oral temperature is important, but there is no indication of infection or fever contributing to fluid loss in this scenario.
C. Inspecting the oral mucosa is correct because the client's total intake (1,245 mL) is significantly lower than their total output (1,928 mL), indicating a negative fluid balance. Signs of dehydration, such as dry oral mucosa, should be assessed first.
D. Auscultating adventitious lung sounds is relevant for fluid overload but is not the priority in a case of fluid deficit.

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Correct Answer is A

Explanation

A. Inflating the blood pressure cuff 30 mmHg above the point where the radial pulse disappears is correct. This method, known as the palpatory method, prevents auscultatory gap errors and ensures an accurate blood pressure reading.
B. Assisting the patient to a standing position for five to ten minutes is incorrect unless assessing for orthostatic hypotension. For routine blood pressure measurements, the client should be seated and at rest for at least five minutes.
C. Palpating the radial artery and placing the stethoscope lightly over this area is incorrect because blood pressure is auscultated over the brachial artery, not the radial artery.
D. Measuring the blood pressure cuff to encircle 60% of the client’s arm is incorrect. The correct guideline is that the cuff bladder should encircle at least 80% of the arm circumference, not 60%.

A. "Do you take painkillers like aspirin on a regular basis?" B. "Are you currently taking vitamin supplements?" C. "Do you tend to eat foods that are quite high in fat?" D. "Do you feel like you're able to accept the stress in your life?"

Correct Answer is A

Explanation

A. Asking about regular painkiller (NSAID) use is correct because nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin and ibuprofen are a major risk factor for peptic ulcer disease. They can damage the gastric mucosa and increase acid production, leading to ulcer formation.
B. Vitamin supplements are not a common cause of peptic ulcer disease. While some supplements can cause gastrointestinal discomfort, they are not a primary risk factor.
C. High-fat foods can contribute to acid reflux or indigestion but are not a direct cause of peptic ulcers. Peptic ulcer disease is primarily linked to Helicobacter pylori infection and NSAID use.
D. Stress was once thought to be a major cause of ulcers, but current research indicates that it plays a minor role compared to factors like H. pylori infection and NSAID use.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing vital signs and is preparing to measure the client's blood pressure. Prior to obtaining the blood pressure, what action would be most appropriate?

Correct Answer is A

Explanation

A client exhibits many of the most common signs and symptoms of peptic ulcer disease. What interview question addresses the most plausible cause of the client's health problem?

Correct Answer is A

Explanation

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include in the education?

A nurse is preparing to examine the chest, extremities, and peripheral pulses of a client who has low back pain. What is the best position to place this client in to assure they are comfortable for the exam?

A nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems?

A 40-year-old client is seen at the clinic with a headache and blurred vision that comes and goes. The client reports a pain of a 6 on a scale from 0–10. What question should the nurse ask to obtain more information about the pattern of the pain?

The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, why does the nurse periodically perform a partial assessment of the client?

A nurse has completed the client's initial assessment and is preparing to identify abnormal data and the client's strengths. Which of the following is required to successfully complete this phase of the nursing process?

After teaching a group of students about changes in body weight due to aging, the instructor determines that the students have understood the teaching when they state which of the following?

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?