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 ["B","C","D","E"]

Explanation

Choice a) is incorrect because nausea is not a common manifestation of ARF. Nausea is a sensation of discomfort in the stomach that may or may not lead to vomiting. Nausea can be caused by many other conditions, such as gastroenteritis, motion sickness, or pregnancy.

Choice b) is correct because severe dyspnea is a common manifestation of ARF. Dyspnea is a subjective feeling of difficulty or discomfort in breathing. Severe dyspnea indicates that the client is not getting enough oxygen and may have low blood oxygen levels (hypoxemia) or high carbon dioxide levels (hypercapnia).

Choice c) is correct because headache is a common manifestation of ARF. Headache is a pain or discomfort in the head, scalp, or neck. Headache can be caused by high carbon dioxide levels (hypercapnia), which can affect the blood vessels and nerves in the brain.

Choice d) is correct because a decreased level of consciousness is a common manifestation of ARF. Level of consciousness is a measure of how alert and oriented a person is. A decreased level of consciousness can be caused by low blood oxygen levels (hypoxemia), high carbon dioxide levels (hypercapnia), or acid-base imbalance, which can aﬀect brain function and mental status.

Choice e) is correct because hypotension is a common manifestation of ARF. Hypotension is a condition in which the blood pressure is lower than normal. Hypotension can be caused by low blood oxygen levels (hypoxemia), which can impair heart function and reduce cardiac output.

A. Initiate droplet precautions. B. Administer an antitoxin. C. Initiate airborne precautions. D. Destroy the linens after use.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because droplet precautions are not sufficient to prevent the transmission of pneumonic plague. Droplet precautions are used to prevent the spread of infectious agents that are expelled through coughing, sneezing, or talking and travel only a short distance in the air. Droplet precautions include wearing a surgical mask, gown, and gloves, and placing the client in a private room or with a roommate who has the same infection.

Choice B Reason: This is incorrect because administering an antitoxin is not an intervention for pneumonic plague. An antitoxin is a substance that neutralizes the eﬀects of a toxin produced by a microorganism. Pneumonic plague is not caused by a toxin, but by a bacterial infection.

Choice C Reason: This is correct because initiating airborne precautions is an intervention for pneumonic plague. Airborne precautions are used to prevent the spread of infectious agents that can remain suspended in the air and travel over long distances. Pneumonic plague is a severe and potentially fatal infection caused by the bacterium Yersinia pestis, which can be transmited through respiratory droplets or aerosols. Airborne precautions are used to prevent the spread of infectious agents that can remain suspended in the air and travel over long distances. Airborne precautions include wearing a respirator or N95 mask, placing the client in a negative-pressure room with an air filtration system, and limiting visitors and staﬀ contact.

Choice D Reason: This is incorrect because destroying the linens after use is not an intervention for pneumonic plague. Linens that are contaminated with body ﬂuids or secretions should be handled with gloves and placed in leak-proof bags for laundering or disposal, but they do not need to be destroyed.

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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?

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Explanation

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