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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A Reason: Swollen, painful joints are not a sign of Lyme disease in the early stage, but they may occur in the late stage, which can take months or years to develop.

Choice B Reason: An expanding circular rash, also known as erythema migrans, is a sign of Lyme disease in the early stage, which usually appears within 3 to 30 days after the tick bite. The rash may have a bull's-eye appearance and can spread up to 12 inches in diameter.

Choice C Reason: Decreased level of consciousness is not a sign of Lyme disease, but it may indicate other serious conditions such as meningitis, encephalitis, or stroke.

Choice D Reason: Necrosis at the site of the bite is not a sign of Lyme disease, but it may indicate a brown recluse spider bite, which can cause tissue damage and ulceration.

A. Hypertension B. Diaphoresis C. Increased thirst D. Muscle tetany

Correct Answer is D

Explanation

Choice A Reason: Hypertension is not a common finding in a client with low calcium level, but it may indicate other conditions such as renal disease or pheochromocytoma.

Choice B Reason: Diaphoresis is not a common finding in a client with low calcium level, but it may indicate other conditions such as fever, anxiety, or hyperthyroidism.

Choice C Reason: Increased thirst is not a common finding in a client with low calcium level, but it may indicate other conditions such as diabetes mellitus, dehydration, or psychogenic polydipsia.

Choice D Reason: Muscle tetany is a common finding in a client with low calcium level, as it indicates that the nerves and muscles are overexcited and contract involuntarily. It may manifest as spasms, cramps, twitching, or tingling sensations.

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A client diagnosed with esophageal varices has a Sengstaken-Blakemore tube. What is the most important safety intervention for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease?

Correct Answer is B

Explanation

I can help you with formatting and editing the text. Here are the edited texts: Text 1: A nurse reviewing the laboratory of a client who had a total thyroidectomy discovers that his calcium level is 7 mg/dL. Which of the following client findings should the nurse expect?

Correct Answer is D

Explanation

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