A nurse on a medical surgical unit is collecting data from an older adult client who has a large amount of abdominal ascites. The client is alert and oriented x3 and states that they walk independently at home and normally use a cane but forgot to bring it to the hospital. Which of the following measures are important for the nurse to initiate first?
Skin safety protocol
Fall risk protocol
Bleeding precaution protocol
Sodium restriction diet
The Correct Answer is B
A. Skin safety protocol: Skin integrity measures are important for clients with ascites but are not the immediate first action for fall risk.
B. Fall risk protocol: Forgetting an assistive device plus altered center of gravity from large ascites increases fall risk - initiating fall precautions (assist with ambulation, provide call light, bedside assistive devices) is the priority for safety.
C. Bleeding precaution protocol: Bleeding precautions may be relevant for cirrhosis with coagulopathy, but fall prevention is more immediately protective for this ambulatory-risk situation.
D. Sodium restriction diet: Dietary sodium restriction helps long-term ascites management but is not the first immediate safety intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Oatmeal:Oatmeal is a low-fat, high-fiber food that is safe and recommended for clients with GERD. It does not exacerbate reflux.
B. Nonfat milk:Nonfat milk is generally neutral and can be consumed safely by clients with GERD. Full-fat dairy may worsen symptoms.
C. Chocolate:Chocolate contains caffeine and theobromine, which relax the lower esophageal sphincter and increase the risk of acid reflux, making it a food to avoid.
D. Apples:Most apples are non-acidic or mildly acidic and are well tolerated; they are not considered major triggers for GERD symptoms.
Correct Answer is D
Explanation
A. Drink cold liquids.:Cold fluids may increase gastric spasms and are not effective in reducing gas.
B. Assume position with legs and rectum lower than the stomach.:This positioning does notrelieve flatus or distension and may worsen discomfort.
C. Use a straw.:Using a straw increases swallowed air, worsening gas and abdominal distension.
D. Ambulate several times a day.:Ambulation promotes peristalsis, reduces gas buildup, and relieves postoperative abdominal distension.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
