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.
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","C","D"]
Explanation
Choice A Reason: This is correct because smallpox is a highly contagious and deadly viral disease that can be used as a biological weapon. Smallpox was eradicated in 1980, but some samples of the virus are still stored in laboratories. If released intentionally, smallpox could cause a global pandemic.
Choice B Reason: This is incorrect because hydrogen cyanide is a chemical weapon of mass destruction, not a biological one. Hydrogen cyanide is a colorless gas that interferes with cellular respiration and causes rapid death.
Choice C Reason: This is correct because botulism is a serious and potentially fatal illness caused by a toxin produced by the bacterium Clostridium botulinum. Botulism can be used as a biological weapon by contaminating food or water supplies or by aerosolizing the toxin.
Choice D Reason: This is correct because anthrax is an infection caused by the spore-forming bacterium Bacillus anthracis. Anthrax can be used as a biological weapon by releasing the spores into the air or by contaminating food or water sources.
Choice E Reason: This is incorrect because sarin is a chemical weapon of mass destruction, not a biological one. Sarin is a nerve agent that blocks the transmission of nerve impulses and causes respiratory failure and death.
Correct Answer is D
Explanation
Choice A: Weight gain is not a manifestation of left-sided heart failure. Weight gain is more likely to occur in right-sided heart failure, as the blood backs up in the systemic circulation and causes fluid retention and edema in the body.
Choice B: Anorexia is not a manifestation of left-sided heart failure. Anorexia is a loss of appetite, which can have many causes, such as psychological disorders, infections, medications, or cancer. Left-sided heart failure does not directly affect appetite, but it can cause nausea, fatigue, and weakness.
Choice C: A distended abdomen is not a manifestation of left-sided heart failure. A distended abdomen is more likely to occur in right-sided heart failure, as the blood backs up in the portal vein and causes increased pressure in the liver and spleen. This can lead to hepatomegaly, splenomegaly, ascites, and varices.
Choice D: Breathlessness is a manifestation of left-sided heart failure. Breathlessness, or dyspnea, is a sensation of difficulty breathing or shortness of breath. Breathlessness occurs in left-sided heart failure, as the blood backs up in the lungs and causes pulmonary congestion and edema. This impairs gas exchange and reduces oxygen delivery to the tissues.
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