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
Documenting the bowel sounds as hypoactive is not the most appropriate action. Hypoactive bowel sounds are fewer than three bowel sound events in a minute or none at all. However, the absence of bowel sounds does not necessarily mean they are hypoactive. It could be due to other reasons such as ileus.
Choice B rationale
Administering prescribed drugs for constipation is not the immediate course of action when the nurse doesn’t hear any gurgling while listening to bowel sounds. Constipation is a condition that can cause hypoactive bowel sounds, but it’s not the only reason for the absence of bowel sounds. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice C rationale

Reviewing dietary intake for the past 24 hours is not the immediate course of action. While diet can affect bowel sounds, it’s not the first step when bowel sounds are not heard. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice D rationale
The correct action when the nurse doesn’t hear any gurgling while listening to bowel sounds is to continue to listen for at least another 60 seconds. Bowel sounds are produced by the movement of fluid, gas, and contents through the intestines. An absence of bowel sounds for greater than two minutes may indicate that there is no peristalsis—which implies an ileus.
Therefore, the nurse should continue to listen for at least another 60 seconds to confirm the absence of bowel sounds.

A. Nonfat milk B. Chocolate C. Oatmeal D. Apples

Correct Answer is B

Explanation

Choice A rationale
Nonfat milk is generally not a trigger for GERD101112131415. It is low in fat and thus less likely to relax the lower esophageal sphincter, which can lead to acid reflux1415.
Choice B rationale

Chocolate is known to trigger GERD symptoms1415. It contains caffeine and fat, which can relax the lower esophageal sphincter and cause acid reflux1415.
Choice C rationale
Oatmeal is generally not a trigger for GERD101112131415. It is a whole grain that is high in fiber, which can help control GERD symptoms1415.
Choice D rationale
Apples are generally not a trigger for GERD101112131415. They are non-citrus fruits and thus less likely to cause acid reflux1415.

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

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?

Correct Answer is B

Explanation

A nurse is educating a client who has hepatitis A on how to prevent the spread of the virus. Which of the following strategies should the nurse include in the teaching?

A nurse is teaching a patient with hepatitis B about self-management. Which instructions should the nurse include in the teaching?

A nurse is caring for a patient who has cirrhosis of the liver and is having difficulty eliminating alcohol consumption because many of their friends drink alcohol socially. Which of the following steps should the nurse include to motivate the patient to change?

A nurse is educating a patient who has a history of ulcerative colitis and has recently been diagnosed with anemia. Which of the following symptoms of colitis should the nurse identify as a contributing factor to the development of anemia?

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?

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 educating a parent of a child diagnosed with celiac disease. Which of the following food choices should the nurse include in the teaching?

A nurse is providing discharge education to a patient who recently experienced an acute gout attack. Which patient statement indicates they have understood the treatment plan?