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 D

Explanation

Choice A rationale
While a nasogastric tube can be used to determine the pH of gastric secretions, this is not typically the primary reason for its use in the treatment of pyloric obstruction.
Choice B rationale
While nasogastric tubes can be used to supply nutrients via tube feedings, this is not typically the primary reason for its use in the treatment of pyloric obstruction. In the case of pyloric obstruction, the focus is usually on relieving the obstruction rather than on feeding.
Choice C rationale
While nasogastric tubes can be used to administer medications, this is not typically the primary reason for its use in the treatment of pyloric obstruction.
Choice D rationale
The primary reason for the use of a nasogastric tube in the treatment of pyloric obstruction is to decompress the stomach. Pyloric obstruction can cause a buildup of gastric contents above the level of the obstruction, leading to symptoms such as nausea and vomiting. A nasogastric tube can be used to remove these contents and relieve symptoms.

A. “It is caused by an increase in intraocular pressure.”. B. “Have an eye exam every 2 years.”. C. “Clouding of the lens is a manifestation of diabetic retinopathy.”. D. “Seeing spots is a manifestation of diabetic retinopathy.”. .

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.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A nurse is educating a patient with diabetes mellitus about diabetic retinopathy. Which of the following statements should the nurse make to the patient?

Correct Answer is D

Explanation

The nurse doesn’t hear any gurgling while listening to bowel sounds. What should be the nurse’s next course of action?

A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care?

For the patient with hypoglycemia who has experienced a suspected seizure, which intervention would the nurse implement immediately?

A nurse is educating a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

A nurse on a medical-surgical unit is caring for four patients who are 24 to 36 hours postoperative. Which of the following surgical procedures places the patient at risk for deep-vein thrombosis?

A nurse is assessing a postoperative client who has anemia due to excessive blood loss during surgery. What findings should the nurse expect?

A nurse is preparing discharge instructions for a patient who has been treated for acute pancreatitis. Which of the following statements is important to include in the instructions?