A client diagnosed with esophageal varices has a Sengstaken-Blakemore tube. What is the most important safety intervention for this client?
Keeping scissors at the bedside
Providing good mouth care
Deflating the balloon on a regular basis
Monitoring IV fluid intake
The Correct Answer is A
Choice A Reason: Keeping scissors at the bedside is the most important safety intervention for this client, as it allows for quick removal of the tube in case of airway obstruction or bleeding.
Choice B Reason: Providing good mouth care is an important intervention for this client, but it is not the most important, as it helps to prevent oral infections and discomfort.
Choice C Reason: Deflating the balloon on a regular basis is not an appropriate intervention for this client, as it may cause bleeding or displacement of the tube.
Choice D Reason: Monitoring IV fluid intake is an important intervention for this client, but it is not the most important, as it helps to prevent fluid overload or dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: If I feel nervous or have tremors, I should not only take half the dose, but I should contact my healthcare provider, as these may indicate signs of overdose or hyperthyroidism.
Choice B Reason: I cannot expect diarrhea, insomnia, and excessive sweating, but these are possible side effects of overdose or hyperthyroidism.
Choice C Reason: I need to call my healthcare provider if my heart rate becomes fast, as this may indicate a serious adverse reaction or overdose of levothyroxine sodium.
Choice D Reason: I should not take the medication in the evening, but in the morning on an empty stomach at least 30 minutes before breakfast, as this ensures better absorption and prevents insomnia.
Correct Answer is ["A","B","C"]
Explanation
Choice A Reason: Heat intolerance is a common finding in hyperthyroidism, as the increased metabolic rate causes the body to produce more heat and sweat.
Choice B Reason: Diarrhea is a common finding in hyperthyroidism, as the increased motility of the gastrointestinal tract causes more frequent and loose stools.
Choice C Reason: Weight loss is a common finding in hyperthyroidism, as the increased metabolism and appetite cause the body to burn more calories than it consumes.
Choice D Reason: Weight gain is not a common finding in hyperthyroidism, but it may indicate other conditions such as hypothyroidism or Cushing's syndrome.
Choice E Reason: Bradycardia is not a common finding in hyperthyroidism, but it may indicate other conditions such as heart block or beta-blocker use.
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