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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
Fluid retention is not typically associated with hyperparathyroidism. Hyperparathyroidism is a condition in which the parathyroid glands produce too much parathyroid hormone, leading to high levels of calcium in the blood.
Choice B rationale
Impaired skin integrity is not typically associated with hyperparathyroidism.
Choice C rationale
Pathologic fractures are a potential complication of hyperparathyroidism. The condition can lead to osteoporosis due to loss of calcium from the bones, increasing the risk of fractures.
Choice D rationale
Dysphagia, or difficulty swallowing, is not typically associated with hyperparathyroidism.

A. Free T4. B. Serum T3. C. Thyroid stimulating hormone (TSH). D. Serum calcium.

Correct Answer is C

Explanation

Choice A rationale
Free T4 levels are typically low in primary hypothyroidism, not elevated.

Choice B rationale
Serum T3 levels are also typically low in primary hypothyroidism.
Choice C rationale
In primary hypothyroidism, the thyroid gland is not producing enough thyroid hormone, leading to an elevated TSH level as the pituitary gland tries to stimulate more hormone production.
Choice D rationale
Serum calcium levels are not directly affected by primary hypothyroidism.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a patient who has a new diagnosis of hyperparathyroidism. The nurse should include in the teaching that the patient is at risk for which of the following complications?

Correct Answer is C

Explanation

A nurse in a clinic is reviewing the laboratory values of a patient who has primary hypothyroidism. The nurse should anticipate an elevation in which of the following laboratory values?

Correct Answer is C

Explanation

A nurse is preparing a care plan for a patient who is about to receive a transfusion of packed red blood cells. What should be the maximum duration for the total infusion time?

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 caring for a client who is receiving one unit of packed red blood cells (RBCs) due to intraoperative blood loss. The client reports chills and back pain, and their blood pressure is 80/64 mm Hg. What should be the nurse’s first action?

A nurse is caring for four hospitalized patients. Which of the following patients should the nurse identify as being at risk for fluid volume deficit?

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

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 caring for a patient who has rheumatoid arthritis and tells the nurse that she wears a copper bracelet to help her feel better. Which of the following responses should the nurse make?

A nurse is educating a client who has recently been diagnosed with gastroesophageal reflux disease (GERD). The client inquires about foods to avoid. Which food should the nurse advise the client to avoid?