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 D
Explanation
Choice A rationale
An increase in intraocular pressure is not a cause of diabetic retinopathy. Diabetic retinopathy is caused by damage to the blood vessels in the retina due to high blood sugar levels.
Choice B rationale
While regular eye exams are important for patients with diabetes mellitus, having an eye exam every 2 years may not be sufficient for detecting and managing diabetic retinopathy. More frequent eye exams may be recommended depending on the patient’s condition.
Choice C rationale
Clouding of the lens is not a manifestation of diabetic retinopathy. This is a symptom of cataracts, not diabetic retinopathy. Diabetic retinopathy affects the blood vessels in the retina, not the lens of the eye.
Choice D rationale
Seeing spots, also known as floaters, is a common symptom of diabetic retinopathy. This occurs when blood and other fluids leak into the vitreous, the clear, jelly-like substance that fills the inside of the eye.
Correct Answer is D
Explanation
Choice A rationale
Hepatitis C is not spread through inhalation. It is a bloodborne virus that is most commonly spread through direct contact with the blood of an infected person.
Choice B rationale
While it is possible for hepatitis C to be spread through semen, this is less common. The risk is higher for men who have sex with men, especially if they are also infected with HIV6.
Choice C rationale
Hepatitis C is not spread through feces. It is a bloodborne virus that is most commonly spread through direct contact with the blood of an infected person.
Choice D rationale
Hepatitis C is primarily spread through blood. This can occur through sharing needles, syringes, or other equipment to inject drugs, or through needle-stick injuries among healthcare workers.
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