Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for an older adult client who has significant issues with ascites related to end-stage liver disease. Which of the following precautions is most important for the nurse to include in the teaching?
A. "An increased weight in the abdomen can lead to problems with getting comfortable when lying down; therefore, have extra pillows in bed."
While having extra pillows can help with comfort, it does not address the primary safety concern associated with ascites, which is the risk of falls due to altered center of gravity and balance.
B. "Due to the increased weight in the abdomen, it is advised that you do not wear undergarments as they may not fit properly."
The advice about undergarments is not a safety precaution but rather a comfort consideration. It is less critical than ensuring the client's safety while ambulating.
C. "Due to the increased abdominal weight, take your time with walking as your balance might be affected and could cause a fall."
This is the correct choice because it directly addresses a significant safety risk for the client. Ascites can greatly affect balance, increasing the risk of falls, which can lead to serious injury, especially in older adults.
D. "The increased weight in your abdomen will mean that you can no longer exercise due to the strain on your heart."
While exercise is important, this statement is overly restrictive and not accurate. Clients with ascites can often still engage in exercise, albeit modified, to accommodate their condition and under medical supervision.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Surg Proctored Exam Midterm Rn 36 1125. Take the full exam now
Full Explanation
Choice A rationale
While having extra pillows can help with comfort, it does not address the primary safety concern associated with ascites, which is the risk of falls due to altered center of gravity and balance.
Choice B rationale
The advice about undergarments is not a safety precaution but rather a comfort consideration. It is less critical than ensuring the client's safety while ambulating.
Choice C rationale
This is the correct choice because it directly addresses a significant safety risk for the client. Ascites can greatly affect balance, increasing the risk of falls, which can lead to serious injury, especially in older adults.
Choice D rationale
While exercise is important, this statement is overly restrictive and not accurate. Clients with ascites can often still engage in exercise, albeit modified, to accommodate their condition and under medical supervision.
Similar Questions
How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis?
A. Percuss between the iliac crest and ribs at the midaxillary line.
Percussion between the iliac crest and ribs at the midaxillary line is not the standard method for assessing flank tenderness associated with pyelonephritis. This technique may not elicit the characteristic pain of kidney inflammation.
B. Push fingers upward into the two lowest intercostal spaces.
Pushing fingers upward into the two lowest intercostal spaces is not a specific test for flank tenderness and may not accurately assess for pyelonephritis. This action is more related to assessing the integrity of the rib cage and intercostal muscles.
C. Palpate along both sides of the lumbar vertebral column.
Palpating along both sides of the lumbar vertebral column is not the correct method for assessing flank tenderness due to pyelonephritis. This approach is more suited for assessing the musculoskeletal structure rather than the kidneys.
D. Strike a flat hand covering the costovertebral angle (CVA).
Striking a flat hand over the costovertebral angle is the correct method for assessing flank tenderness in cases of suspected pyelonephritis. This technique, known as costovertebral angle tenderness, elicits pain when the kidneys are inflamed, which is a common sign of pyelonephritis.
Full Explanation
Choice A rationale
Percussion between the iliac crest and ribs at the midaxillary line is not the standard method for assessing flank tenderness associated with pyelonephritis. This technique may not elicit the characteristic pain of kidney inflammation.
Choice B rationale
Pushing fingers upward into the two lowest intercostal spaces is not a specific test for flank tenderness and may not accurately assess for pyelonephritis. This action is more related to assessing the integrity of the rib cage and intercostal muscles.
Choice C rationale
Palpating along both sides of the lumbar vertebral column is not the correct method for assessing flank tenderness due to pyelonephritis. This approach is more suited for assessing the musculoskeletal structure rather than the kidneys.
Choice D rationale
Striking a flat hand over the costovertebral angle is the correct method for assessing flank tenderness in cases of suspected pyelonephritis. This technique, known as costovertebral angle tenderness, elicits pain when the kidneys are inflamed, which is a common sign of pyelonephritis.
Which clinical manifestation of inflammatory bowel disease is common to both patients with ulcerative colitis (UC) and Crohn's disease?
A. Diarrhea stools
Diarrhea is a common symptom in both ulcerative colitis (UC) and Crohn's disease, often presenting with urgency and frequency.
B. Lesions that penetrate the intestine
Lesions that penetrate the intestine are more characteristic of Crohn's disease, which can affect any layer of the intestinal wall and any part of the gastrointestinal tract.
C. Strictures are common
Strictures are more common in Crohn's disease due to its transmural inflammatory nature, which can lead to fibrosis and narrowing of the intestines¹.
D. Restricted to rectum
UC is restricted to the colon and often involves the rectum, but Crohn's disease can affect any part of the gastrointestinal tract from the mouth to the anus and is not restricted to the rectum¹.
Full Explanation
Choice A rationale
Diarrhea is a common symptom in both ulcerative colitis (UC) and Crohn's disease, often presenting with urgency and frequency.
Choice B rationale
Lesions that penetrate the intestine are more characteristic of Crohn's disease, which can affect any layer of the intestinal wall and any part of the gastrointestinal tract.
Choice C rationale
Strictures are more common in Crohn's disease due to its transmural inflammatory nature, which can lead to fibrosis and narrowing of the intestines¹.
Choice D rationale
UC is restricted to the colon and often involves the rectum, but Crohn's disease can affect any part of the gastrointestinal tract from the mouth to the anus and is not restricted to the rectum¹.
In an effort to decrease the rate of urinary tract infections, which of the following should the nurse manager teach the nursing staff? (Select all that apply)
A. Obtain orders from the health care provider to discontinue catheters as soon as possible.
Removing catheters as soon as they are no longer necessary can significantly reduce the risk of catheter-associated urinary tract infections (CAUTIs)¹.
B. Remind clients to urinate right away when they have an urge and to completely empty their bladder.
While it is important for clients to urinate when they feel the urge, this practice alone is not specifically targeted at reducing the rate of urinary tract infections.
C. Promote perineal care that includes wiping the perineum from front to back.
Teaching proper perineal care, including wiping from front to back, can help prevent the spread of bacteria to the urethra and reduce the risk of UTIs¹.
D. Encourage continuing prescribed antibiotics even if the client's symptoms have subsided.
Continuing prescribed antibiotics until the full course is completed, even if symptoms improve, is crucial to ensure all bacteria are eliminated and to prevent antibiotic resistance³.
E. Encourage adequate fluid intake every day if appropriate.
Adequate fluid intake helps flush bacteria from the urinary tract, which can decrease the incidence of UTIs¹.
Full Explanation
Choice A rationale
Removing catheters as soon as they are no longer necessary can significantly reduce the risk of catheter-associated urinary tract infections (CAUTIs)¹.
Choice B rationale
While it is important for clients to urinate when they feel the urge, this practice alone is not specifically targeted at reducing the rate of urinary tract infections.
Choice C rationale
Teaching proper perineal care, including wiping from front to back, can help prevent the spread of bacteria to the urethra and reduce the risk of UTIs¹.
Choice D rationale
Continuing prescribed antibiotics until the full course is completed, even if symptoms improve, is crucial to ensure all bacteria are eliminated and to prevent antibiotic resistance³.
Choice E rationale
Adequate fluid intake helps flush bacteria from the urinary tract, which can decrease the incidence of UTIs¹.