A client is receiving care following the insertion of a Sengstaken-Blakemore tube for esophageal variceal hemorrhage. Which of the following nursing actions is most critical to monitor for potential complications during this intervention?
Assess the client for respiratory distress and signs of aspiration.
Confirm the lumens of the tube are properly labeled.
Monitor the gastric balloon pressure every hour.
Ensure the client is in a supine position for comfort.
The Correct Answer is A
A Sengstaken-Blakemore tube is used as an emergency measure to control life-threatening bleeding from esophageal varices by applying direct pressure to bleeding sites using inflated gastric and esophageal balloons. This intervention carries significant risks, including airway obstruction, aspiration, and esophageal rupture. Because the tube is placed near the airway and upper gastrointestinal tract, maintaining airway patency and preventing aspiration are the highest priorities during care.
Rationale:
A. Assessing the client for respiratory distress and signs of aspiration is the most critical nursing action because inflation of the balloons can compress the airway and increase the risk of aspiration of blood or gastric contents. Any signs of dyspnea, hypoxia, or coughing may indicate airway compromise, which requires immediate intervention to prevent respiratory failure.
B. Confirming the lumens of the tube are properly labeled is important for correct management of the gastric and esophageal ports but is not the most urgent priority. While proper labeling helps ensure correct inflation and drainage, it does not address immediate life-threatening complications such as airway obstruction or aspiration.
C. Monitoring the gastric balloon pressure every hour is necessary to ensure the balloon is providing adequate tamponade without causing tissue damage or rupture. However, this is a secondary monitoring task compared to airway safety. Overinflation risks esophageal necrosis, but airway protection remains the primary concern.
D. Ensuring the client is in a supine position for comfort is incorrect because the supine position increases the risk of aspiration in a client with active upper gastrointestinal bleeding. The client should typically be positioned with the head elevated or in a lateral position to reduce aspiration risk and support airway protection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Bone marrow suppression is a common adverse effect of cytotoxic and antimetabolite therapies such as Methotrexate. This condition results in decreased production of blood cells, leading to anemia, leukopenia, and thrombocytopenia. Because the bone marrow is responsible for hematopoiesis, monitoring blood cell counts is essential to evaluate recovery and detect toxicity early. Improvement is primarily reflected in normalization of circulating blood cell lines.
Rationale:
A. A complete blood count (CBC) is the most appropriate laboratory test to monitor improvement in bone marrow suppression. It directly measures white blood cells, red blood cells, hemoglobin, hematocrit, and platelets, all of which are affected by methotrexate toxicity. Rising counts toward normal ranges indicate recovery of bone marrow function and improved hematopoiesis.
B. Renal function tests are important in clients receiving methotrexate because the drug is primarily excreted by the kidneys and can accumulate in renal impairment. However, these values assess drug clearance and toxicity risk rather than recovery from bone marrow suppression. They do not directly reflect improvement in blood cell production.
C. Liver function tests (LFTs) are monitored because methotrexate can cause hepatotoxicity with prolonged use. While they help detect liver injury, they are not indicators of bone marrow recovery. Improvement in bone marrow function is not reflected in hepatic enzyme levels.
D. Blood chemistry panels assess electrolytes and metabolic status, which may be indirectly affected in critically ill patients. However, they do not provide specific information about bone marrow activity or hematologic recovery. Therefore, they are not useful for evaluating improvement in bone marrow suppression.
Correct Answer is ["B","E","F"]
Explanation
Correct placement of an endotracheal tube after intubation is critical to ensure effective ventilation and prevent complications such as esophageal intubation or right mainstem bronchus placement. Verification requires a combination of clinical assessment and objective confirmation. Relying on a single method is unsafe, so multiple validation techniques are used to ensure accurate airway placement and adequate oxygenation.
Rationale:
A. Verifying the color of the tube is not a reliable method to confirm endotracheal tube placement. Tube color does not change based on anatomical position and provides no information about whether the tube is in the trachea or esophagus. This method is not used in clinical practice for confirmation of airway placement.
B. Observing symmetrical chest expansion helps assess whether both lungs are being ventilated. Unequal or absent chest movement may suggest endobronchial intubation or esophageal placement. While helpful, it must be used alongside other objective confirmation methods for accuracy.
C. Administering a dose of oxygen is not a verification method for tube placement. While oxygen delivery is essential after intubation, it does not confirm whether the tube is correctly positioned in the trachea. Oxygen administration is supportive care, not a diagnostic confirmation technique.
D. Measuring the external length of the tube from the lips is a method used to monitor for dislodgement or movement after the initial position has already been confirmed. While it helps ensure the tube stays in the same place (e.g., "22 cm at the teeth"), it cannot prove that the initial placement was in the trachea rather than the esophagus.
E. Auscultating for breath sounds bilaterally is a key method for verifying correct placement. Equal breath sounds over both lung fields suggest tracheal placement, while absent or unequal sounds may indicate esophageal or bronchial intubation. This method should always be combined with additional confirmation techniques.
F. Checking end-tidal carbon dioxide (EtCO₂) levels is the most reliable method for confirming tracheal placement. Presence of sustained CO₂ indicates that the tube is in the airway and that ventilation is occurring. This capnography confirmation is considered the gold standard for verifying correct endotracheal tube placement.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.