A nurse is caring for a client who has bleeding esophageal varices and is being treated with a Sengstaken-Blakemore tube. Which of the following actions should the nurse perform?
Deflate the balloons for 5 min every 2 hr to prevent tissue necrosis.
Keep the head of the bed flat at all times to prevent the development of shock.
Maintain constant observation while the balloons are inflated.
Suction the tube every 2 hr and as needed to maintain patency.
Suction the tube every 2 hr and as needed to maintain patency.
The Correct Answer is C
Choice A Reason: This is incorrect. The balloons should not be deflated without a physician's order, as this can cause rebleeding or aspiration.
Choice B Reason: This is incorrect. The head of the bed should be elevated to 30 to 45 degrees to reduce pressure on the balloons and prevent gastric reflux.
Choice C Reason: This is correct. The nurse should monitor the client closely for signs of complications, such as airway obstruction, aspiration, or balloon rupture. The nurse should also keep scissors at the bedside to cut the tube and release the balloons in case of an emergency.
Choice D Reason: This is incorrect. The tube should not be suctioned, as this can damage the mucosa and cause bleeding. The nurse should only aspirate gastric contents through the gastric lumen to decompress the stomach.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Cold and numb sensation distal to the fistula site is a possible indication of venous insufficiency. Venous insufficiency is a condition in which the veins have difficulty returning blood from the limbs to the heart, resulting in blood pooling and reduced perfusion. A new arteriovenous fistula can cause increased blood flow through the artery and decreased blood flow through the vein, leading to venous insufficiency. This can manifest as coldness, numbness, tingling, or cyanosis in the fingers or hand below the fistula site.
Choice B: A raised red rash around the fistula site is not a possible indication of venous insufficiency. A raised red rash around the fistula site can indicate an allergic reaction, an infection, or an inflammation of the skin or subcutaneous tissue. The nurse should assess the rash for size, shape, color, texture, temperature, and drainage, and report any signs of infection or inflammation, such as fever, pus, or swelling.
Choice C: Pain in the right arm proximal to the fistula site is not a possible indication of venous insufficiency. Pain in the right arm proximal to the fistula site can indicate arterial insufficiency, which is a condition in which the arteries have difficulty delivering oxygen-rich blood to the tissues, resulting in ischemia and necrosis. Arterial insufficiency can be caused by atherosclerosis, thrombosis, embolism, or vasospasm. The nurse should assess the pain for location, intensity, duration, frequency, and quality, and report any signs of ischemia or necrosis, such as pallor, coolness, weak pulses, or ulceration.
Choice D: Foul-smelling drainage from the fistula site is not a possible indication of venous insufficiency. Foul-smelling drainage from the fistula site can indicate an infection of the fistula or surrounding tissue. The nurse should assess the drainage for color, odor, amount, and consistency, and report any signs of infection or sepsis, such as fever, chills, malaise, or hypotension.
Correct Answer is ["A","C","E"]
Explanation
Choice A Reason: This is correct because placing ice to the bridge of the client’s nose can cause vasoconstriction and reduce blood flow to the nasal mucosa.
Choice B Reason: This is incorrect because tilting the client's head backward can cause blood to drain into the throat and increase the risk of aspiration, nausea, and vomiting.
Choice C Reason: This is correct because moving the client into high-Fowler position can lower the blood pressure in the head and neck and decrease bleeding.
Choice D reason Reason This is incorrect because instructing the client to blow his nose can dislodge any clots that have formed and worsen bleeding.
Choice E Reason: This is correct because applying pressure to the nares can compress the bleeding site and promote clotting.
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