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 C
Explanation
Choice A: Hct 45% is not a value that the nurse should report to the provider. Hct, or hematocrit, is the percentage of red blood cells in the total blood volume. The normal range for Hct is 37% to 51% for men and 32% to 45% for women. Hct 45% is within the normal range and does not indicate any abnormality.
Choice B: Platelets 160,000/mm³ is not a value that the nurse should report to the provider. Platelets, or thrombocytes, are cell fragments that help with blood clotting and hemostasis. The normal range for platelets is 150,000 to 450,000/mm³. Platelets 160,000/mm³ is within the normal range and does not indicate any abnormality.
Choice C: WBC 1,700/mm³ is a value that the nurse should report to the provider. WBC, or white blood cells, are cells that fight infection and inflammation. The normal range for WBC is 4,500 to 11,000/mm³. WBC 1,700/mm³ is below the normal range and indicates leukopenia, which is a low number of white blood cells. Leukopenia can be caused by various conditions, such as viral infections, autoimmune disorders, bone marrow suppression, or chemotherapy. Leukopenia can increase the risk of infection and sepsis and requires prompt evaluation and treatment.
Choice D: Hgb 14.7 g/dL is not a value that the nurse should report to the provider. Hgb, or hemoglobin, is a protein in red blood cells that carries oxygen to the tissues. The normal range for Hgb is 13.5 to 17.5 g/dL for men and 12.0 to 15.5 g/dL for women. Hgb 14.7 g/dL is within the normal range and does not indicate any abnormality.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect. Anginal pain usually lasts less than 20 min and subsides with rest or medication. Pain that lasts longer than 20 min may indicate a myocardial infarction.
Choice B Reason: This is incorrect. Anginal pain usually responds to rest and organic nitrates, such as nitroglycerin. Pain that does not improve with these measures may indicate unstable angina or a myocardial infarction.
Choice C Reason: This is incorrect. Anginal pain is not affected by the position of the client. Pain that is relieved by sitting up may indicate pericarditis or pleurisy.
Choice D Reason: This is correct. Anginal pain is caused by a temporary imbalance between the oxygen demand and supply of the myocardium. Factors that increase the oxygen demand, such as exertion, anxiety, cold, or heavy meals, can trigger anginal pain.
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