A patient with ascites has been admitted to your unit. Which of the following safety precautions should you reinforce to prevent complications?
Instruct the patient to change positions slowly prevent dizziness and falls.
Advise the patient to avoid all physical activity to prevent exacerbation of symptoms.
Encourage the patient to drink plenty of fluids to prevent dehydration.
Recommend wearing tight clothing to support the abdominal area.
The Correct Answer is A
A. Instruct the patient to change positions slowly to prevent dizziness and falls. Ascites can cause a shift in fluid balance, leading to orthostatic hypotension. Changing positions slowly reduces the risk of dizziness and falls, which are common in patients with fluid shifts.
B. Advise the patient to avoid all physical activity to prevent exacerbation of symptoms: Complete avoidance of physical activity is not recommended. Mild activity may help with overall health and mobility unless contraindicated. Bedrest is typically only recommended for acute or severe cases.
C. Encourage the patient to drink plenty of fluids to prevent dehydration: Patients with ascites are often on fluid restrictions to manage excess fluid accumulation. Encouraging excess fluid intake can worsen the condition.
D. Recommend wearing tight clothing to support the abdominal area: Tight clothing could cause discomfort and increase abdominal pressure, which could exacerbate symptoms or complications related to ascites.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "You will need to avoid high-fiber foods to prevent blockages": While caution with high-fiber foods may be needed initially, long-term, a balanced diet including fiber can help regulate bowel movements and prevent constipation. This statement could cause unnecessary concern.
B. "The output from your stoma will be mostly liquid": This statement is incorrect for a sigmoid colostomy, where the stool tends to be more formed since it is further along the digestive tract. Liquid output is more common with ileostomies or colostomies higher in the colon.
C. "You will need to change your colostomy bag every 24 hours":
Rationale: Colostomy bag changes depend on several factors, including the type of appliance and personal preferences. Bags are not changed on a strict 24-hour schedule but are emptied as needed and changed every few days or when required.
D. "Your stoma will be located on the left side of your abdomen." A sigmoid colostomy is typically located on the left lower quadrant of the abdomen, as this is the anatomical location of the sigmoid colon.
Correct Answer is B
Explanation
A. Intestinal obstruction: While peritonitis can lead to intestinal obstruction, it is not the most immediate life-threatening complication compared to hypovolemic shock or sepsis.
B. Hypovolemic shock: This is a critical condition that can occur due to severe fluid loss, which might be a concern in peritonitis due to fluid shifts into the abdominal cavity. However, the patient’s signs of systemic infection (fever, elevated heart rate, low blood pressure) suggest that sepsis is a more imminent threat.
C. Electrolyte imbalance: Electrolyte imbalances are possible due to fluid loss, but they would be secondary to the more urgent concern of hypovolemic shock.
D. Sepsis: Sepsis is the highest priority due to the patient’s vital signs and symptoms indicating a systemic infection. Early recognition and treatment of sepsis are crucial to prevent organ failure and other severe complications.
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