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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Limiting fluid intake to 1 liter per day is not recommended for patients who have experienced an acute gout attack. Adequate hydration is important for all individuals, especially those with gout, as it can help to prevent the formation of uric acid crystals.
Choice B rationale
Taking one aspirin every day is not typically recommended for gout patients. Aspirin can actually increase uric acid levels in the blood and potentially trigger a gout attack.
Choice C rationale
Adhering to a high-purine diet is not recommended for gout patients. Foods high in purines can increase uric acid levels in the blood, potentially triggering a gout attack.
Choice D rationale
Restricting alcohol consumption is a key part of managing gout. Alcohol, especially beer, can increase uric acid levels in the blood and trigger gout attacks.
Correct Answer is D
Explanation
Choice A rationale
The situation component of the SBAR tool typically involves a brief description of the current problem or concern. Stating that a bowel resection was performed does not describe a current problem or concern.
Choice B rationale
The recommendation component of the SBAR tool involves suggesting a course of action or asking for assistance. Stating that a bowel resection was performed does not suggest a course of action or ask for assistance.
Choice C rationale
The assessment component of the SBAR tool involves sharing your analysis or opinion about the situation. Stating that a bowel resection was performed does not share an analysis or opinion.
Choice D rationale
This is the correct answer. The background component of the SBAR tool involves providing context or background information relevant to the situation. Stating that a bowel resection was
performed provides relevant background information about the patient’s recent medical history. DysphagiaDysphagia Explore
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