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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason: This is incorrect because magnesium is not a medication for symptomatic bradycardia. Magnesium is a mineral that regulates muscle and nerve function, blood pressure, and blood sugar levels. Magnesium can be used to treat conditions such as torsades de pointes, eclampsia, or hypomagnesemia.

Choice B Reason: This is incorrect because sodium bicarbonate is not a medication for symptomatic bradycardia. Sodium bicarbonate is a substance that neutralizes acids and bases and regulates the pH of the blood. Sodium bicarbonate can be used to treat conditions such as metabolic acidosis, cardiac arrest, or overdose of certain drugs.

Choice C Reason: This is incorrect because epinephrine is not a medication for symptomatic bradycardia. Epinephrine is a hormone that activates the sympathetic nervous system and increases the heart rate, blood pressure, and blood ﬂow to the muscles and brain. Epinephrine can be used to treat conditions such as anaphylaxis, cardiac arrest, or severe asthma.

Choice D Reason: This is correct because atropine is a medication for symptomatic bradycardia. Atropine blocks the action of the parasympathetic nervous system and increases the heart rate and conduction. Atropine is a medication that blocks the action of the parasympathetic nervous system and increases the heart rate and conduction.

Symptomatic bradycardia is a condition where the heart rate is slower than normal and causes symptoms such as dizziness, fatigue, chest pain, or fainting. Atropine can be used to treat symptomatic bradycardia by stimulating the sinoatrial node and the atrioventricular node, which are the natural pacemakers of the heart.

A. Sinus bradycardia B. Sinus tachycardia C. Atrial fibrillation D. First-degree AV block

Correct Answer is C

Explanation

Choice A Reason: This is incorrect. Sinus bradycardia is a slow and regular heart rate that originates from the sinus node. It does not cause irregular palpitations, fatigue, or dizziness, unless the heart rate is very low or the client has underlying cardiac disease.

Choice B reason: This is incorrect. Sinus tachycardia is a fast and regular heart rate that originates from the sinus node. It may cause fatigue or dizziness, but not irregular palpitations or pulse deficit.

Choice C Reason: This is correct. Atrial fibrillation is a fast and irregular heart rate that originates from multiple foci in the atria. It causes irregular palpitations, fatigue, dizziness, and pulse deficit due to ineﬀective atrial contractions and variable ventricular response.

Choice D Reason: This is incorrect. First-degree AV block is a delay in the conduction of impulses from the atria to the ventricles. It does not aﬀect the heart rate or rhythm, and does not cause any symptoms.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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