A client with cirrhosis is admitted with hematemesis and tachycardia. The nurse suspects variceal bleeding. Which action should the nurse take first?

Administer IV proton pump inhibitors

Prepare for endoscopic band ligation

Initiate IV vasopressin infusion

Assess airway and breathing

Answer and Explanation

The Correct Answer is D

Choice A reason: IV proton pump inhibitors reduce gastric acid, preventing ulcer-related bleeding, but variceal bleeding in cirrhosis results from portal hypertension, not acid-related injury. Hematemesis risks airway aspiration, making airway assessment the priority. Proton pump inhibitors are supportive but not the first action in acute variceal bleeding with potential airway compromise.

Choice B reason: Endoscopic band ligation is a definitive treatment for variceal bleeding, occluding bleeding esophageal varices. However, it requires preparation and sedation, delaying intervention. Hematemesis and tachycardia suggest active bleeding, risking airway aspiration. The ABCDE approach prioritizes airway assessment to ensure patency before procedural interventions like endoscopy.

Choice C reason: IV vasopressin reduces portal pressure, controlling variceal bleeding, but it acts over time and may cause vasoconstriction-related complications. Hematemesis poses an immediate airway risk due to aspiration. The ABCDE approach prioritizes airway and breathing assessment to prevent respiratory compromise, making vasopressin a secondary intervention in this acute scenario.

Choice D reason: Hematemesis in variceal bleeding risks airway aspiration, a life-threatening complication, especially with tachycardia indicating hypovolemia. Assessing airway and breathing ensures patency and adequate oxygenation, critical in the ABCDE approach. This is the first action to prevent respiratory arrest, prioritizing airway protection before addressing bleeding or hemodynamic instability in cirrhosis.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"D"}

Explanation

When assessing a client with suspected ventilatory failure, potential indicators include decreased PaO2, increased heart rate, and increased PaCO2.

A. Decreased PaO2 is a key indicator of ventilatory failure. The client’s PaO2 levels of 60 mmHg at 1030 and 55 mmHg at 1200, compared to the reference range of 75-100 mmHg, show impaired oxygen exchange, reflecting inadequate ventilation. This aligns with the client’s low oxygen saturation (88% and 85%) and symptoms like dyspnea and accessory muscle use, indicating respiratory distress.

B. Increased heart rate is another indicator. The client’s heart rate rose from 110/min at 1030 to 115/min at 1200, above normal ranges, suggesting a compensatory response to hypoxia and respiratory distress. This tachycardia, coupled with symptoms like fatigue and difficulty speaking, supports ventilatory failure as the body attempts to meet oxygen demands, aligning with Maslow’s physiological needs for oxygenation.

C. High oxygen saturation is not an indicator of ventilatory failure. The client’s oxygen saturation is low (88% at 1030, 85% at 1200), which is consistent with ventilatory failure, not high saturation. High oxygen saturation would suggest adequate oxygenation, contradicting the client’s clinical presentation of wheezing, decreased breath sounds, and low PaO2.

D. Increased PaCO2 is a hallmark of ventilatory failure. The client’s PaCO2 levels of 54 mmHg at 1030 and 58 mmHg at 1200, above the reference range of 35-45 mmHg, indicate CO2 retention due to inadequate ventilation. This, along with the client’s respiratory acidosis (pH 7.32 and 7.30) and symptoms like increased respiratory rate and fatigue, confirms ventilatory failure.

A. Administer IV mannitol B. Elevate the head of the bed to 30 degrees C. Initiate seizure prophylaxis D. Increase sedation

Correct Answer is B

Explanation

Choice A reason: IV mannitol reduces intracranial pressure by drawing fluid from brain tissue, but it requires a provider’s order and time to act. ICP of 22 mm Hg is elevated, and elevating the head of the bed is a non-invasive, immediate intervention to promote venous drainage, making it the priority action.

Choice B reason: An ICP of 22 mm Hg indicates elevated intracranial pressure, risking brain herniation. Elevating the head of the bed to 30 degrees promotes cerebral venous drainage, reducing ICP immediately. This non-invasive intervention aligns with the ABCDE approach’s focus on preventing neurological deterioration, making it the first action in traumatic brain injury management.

Choice C reason: Seizure prophylaxis prevents complications in traumatic brain injury but does not directly address elevated ICP (22 mm Hg). Seizures increase ICP further, but immediate pressure reduction is critical to prevent herniation. Head elevation is a faster, non-invasive intervention, making seizure prophylaxis secondary in this acute scenario.

Choice D reason: Increasing sedation controls agitation, which can raise ICP, but it risks respiratory depression and requires careful monitoring. ICP of 22 mm Hg needs immediate reduction, and head elevation promotes venous drainage without delay. Sedation is a supportive measure, making it less urgent than positioning to lower ICP.

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A client with cirrhosis is admitted with hematemesis and tachycardia. The nurse suspects variceal bleeding. Which action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the emergency department. Exhibits When assessing a client with suspected ventilatory failure, potential indicators include dropdown, dropdown, and dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"D"}

Explanation

A nurse is caring for a client with a traumatic brain injury in the ICU. The client’s intracranial pressure (ICP) is 22 mm Hg. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

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