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?

The correct answer is D. Blood pressure 115/68 mm Hg.

Choice A reason: Heart rate 180/min is incorrect because, although an increased heart rate is a compensatory mechanism, a rate of 180/min is excessively high and suggests a more severe stage of shock or other cardiac issues.

Choice B reason: Mottled skin is incorrect as it indicates poor perfusion seen in decompensated shock, where organ dysfunction begins to manifest, not in the compensatory stage.

Choice C reason: Hypokalemia, or low potassium levels, is incorrect because electrolyte imbalances are not typically a finding in the compensatory stage of shock. Normal potassium levels range from 3.5 to 5.0 mEq/L.

Choice D reason: Blood pressure 115/68 mm Hg is correct because it falls within the normal blood pressure range, which the body strives to maintain during the compensatory stage of shock through various mechanisms.

Choice A: Inspecting the electrode pads is an action that the nurse should take. The electrode pads are adhesive patches that atach to the skin and connect to the ECG machine. The nurse should inspect the electrode pads for expiration date, cleanliness, and stickiness, and replace them if necessary. The nurse should also check for any signs of skin irritation or allergy from the electrode pads.

Choice B: Instructing the client not to talk during the test is an action that the nurse should take. Talking during the test can interfere with the ECG recording and cause artifacts or false readings. The nurse should instruct the client to remain still and quiet during the test, and avoid any movements or activities that can affect the heart rate or rhythm, such as coughing, deep breathing, or shivering.

Choice C: Administering an analgesic prior to the procedure is not an action that the nurse should take. An analgesic is a pain reliever that can be given orally, intravenously, or topically. An analgesic is not necessary for an ECG, as it is a noninvasive and painless procedure. An analgesic can also alter the heart rate or rhythm and affect the ECG results. The nurse should only administer an analgesic if prescribed by the provider for another reason.

Choice D:It is more common to use alcohol swabs, and not water, to clean the skin as they are better at removing oils and ensuring good adhesion of the electrodes.

Choice E: Keeping the client NPO after midnight is not an action that the nurse should take. NPO means nothing by mouth, which is a restriction of food and fluids before certain procedures or surgeries. NPO is not required for an ECG, as it does not involve any anesthesia or sedation. The nurse should allow the client to eat and drink normally before and after the test, unless instructed otherwise by the provider.