A nurse is caring for a client who was admited with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?

Provide frequent oral and nares care

Keep the client in a supine position

Ambulate the client four times per day

Encourage the client to consume clear liquids

Answer and Explanation

The Correct Answer is A

Choice A: Provide frequent oral and nares care is the correct action for the nurse to take. Oral and nares care can help prevent infection, dryness, and irritation of the mucous membranes, which can be damaged by the pressure and friction of the tube. The nurse should also monitor the tube position, secure it with tape, and keep scissors at the bedside in case of emergency deﬂation.

Choice B: Keep the client in a supine position is not the correct action for the nurse to take. The supine position can increase the risk of aspiration, regurgitation, and gastric distension, which can worsen the bleeding and compromise the airway. The nurse should elevate the head of the bed to at least 30 degrees and use a semi-Fowler's or high-Fowler's position.

Choice C: Ambulating the client four times per day is not the correct action for the nurse to take. Ambulation can increase abdominal pressure and dislodge the tube, which can cause bleeding and perforation. The nurse should keep the client on bed rest and use passive range-of-motion exercises to prevent complications such as thromboembolism and muscle atrophy.

Choice D: Encouraging the client to consume clear liquids is not the correct action for the nurse to take. Clear liquids can increase gastric volume and acidity, which can aggravate the bleeding and interfere with hemostasis. The nurse should maintain a nothing-by-mouth status and provide intravenous ﬂuids and nutrition as prescribed.

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Correct Answer is C

Explanation

Choice A: Removing the elastic bandages is not recommended. These bandages help slow the spread of venom by compressing the lymphatic vessels. Removing them could worsen the envenomation.

Choice B: This is incorrect. The nurse should not discharge the client, as they may develop serious complications from the snake bite, such as swelling, bleeding, infection, or shock. The client should be monitored closely and treated accordingly.

Choice C: This is the correct action. Antivenom treatment is crucial for serious snake envenomation. The sooner it can be administered, the better the outcome.

Choice D: While pain management is important, it is not the priority in this situation. Antivenom takes precedence over pain medication.

A. Shortening of P-wave duration B. Restoration of QRS complex amplitude C. Reduction of T-wave amplitude D. Widening of the QRS complex

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because shortening of P-wave duration is not a sign of hyperkalemia or its reversal.

P-wave duration reﬂects the time it takes for the atria to depolarize and contract.

Choice B Reason: This is incorrect because restoration of QRS complex amplitude is not a sign of hyperkalemia or its reversal. QRS complex amplitude reﬂects the voltage or strength of the ventricular depolarization and contraction.

Choice C Reason: This is correct because the reduction of T-wave amplitude is a sign of hyperkalemia reversal. T-wave amplitude reﬂects the repolarization or recovery of the ventricles after contraction. Polystyrene sulfonate is a medication that lowers the serum potassium level by binding to it in the gastrointestinal tract and excreting it in the stool. High serum potassium level, or hyperkalemia, can cause cardiac arrhythmias and ECG changes, such as peaked T waves, prolonged PR interval, ﬂatened P waves, widened QRS complex, and ventricular fibrillation. By lowering the serum potassium level, polystyrene sulfonate can reverse these ECG changes and normalize the cardiac rhythm.

Choice D Reason: This is incorrect because the widening of the QRS complex is a sign of hyperkalemia, not its reversal. Widening of the QRS complex reﬂects the delay or impairment of ventricular depolarization and contraction.

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A nurse is caring for a client who was admited with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is assessing a client who was biten on the left leg by a poisonous snake. The client has placed elastic bandages snugly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is eﬀective, the nurse should expect which of the following changes on the client’s ECG?

Correct Answer is C

Explanation

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