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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Auscultation of a bruit over the pedal pulse is not a typical symptom of DVT. A bruit is a sound heard over an artery due to turbulent blood flow. While it may indicate vascular disease, it is not a symptom of DVT121314.
Choice B rationale
Groin tenderness can be a symptom of DVT. DVT often causes pain or tenderness in the affected area, which can include the groin.
Choice C rationale
Pallor in the affected extremity is not a typical symptom of DVT. DVT can cause swelling and warmth in the affected area, but it does not typically cause pallor.
Choice D rationale
Cramping pain in one foot is not a typical symptom of DVT. DVT often causes pain or swelling in the affected leg, but the pain is not typically limited to the foot.
Correct Answer is A
Explanation
Choice A rationale
Diabetes mellitus is a risk factor for urinary tract infections (UTIs). High blood sugar levels can impair the immune system, making it harder for the body to fight off infections. Additionally, diabetes can cause nerve damage that affects the bladder’s ability to empty completely, allowing bacteria to grow.
Choice B rationale
Anemia itself is not a direct risk factor for UTIs. Anemia is a condition characterized by a lack of healthy red blood cells or hemoglobin, which does not contribute to the development of UTIs.
Choice C rationale
Chronic Obstructive Pulmonary Disease (COPD) primarily affects the lungs and does not increase the risk of UTIs. COPD can make it harder to breathe, but it does not have a direct impact on the urinary system.
Choice D rationale
Osteoporosis is a condition that weakens bones, making them fragile and more likely to break. It does not increase the risk of UTIs. Osteoporosis and UTIs are not directly related as they affect different systems within the body.
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