A patient is being treated for bleeding esophageal varices with balloon tamponade. Which of the following nursing actions will the nurse include in the plan of care?

Administer anticoagulant medications.

Monitor vital signs every 4 hours.

Encourage the patient to consume a high-fiber diet.

Assist with the insertion and removal of the balloon tamponade device.

Answer and Explanation

The Correct Answer is B

A. Administering anticoagulant medications is contraindicated in patients with bleeding esophageal varices. Anticoagulants could worsen bleeding and complicate the condition further. The goal in managing esophageal varices is to control the bleeding, not to increase the risk of bleeding.
B. Monitoring vital signs frequently is critical in patients with bleeding esophageal varices, as they are at risk for hypovolemic shock. Vital signs should be monitored closely to assess for signs of bleeding, hemodynamic instability, and response to interventions. Typically, more frequent monitoring (every 15 minutes initially, then every hour) is indicated, not just every 4 hours.
C. A high-fiber diet is not appropriate for patients with bleeding esophageal varices. This can increase intra-abdominal pressure and may worsen bleeding. The diet should be tailored to the patient's needs, typically involving low-residue or soft foods depending on their condition.
D. Assisting with the insertion and removal of the balloon tamponade device should be done by a skilled provider, not the nurse. The nurse's role involves monitoring for complications, ensuring proper positioning, and assessing the patient's response to treatment.

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Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

Rationale:

Hypoxia: The client's decreased oxygen saturation (SaO2) despite oxygen therapy and the presence of respiratory distress (tachypnea, shortness of breath) indicate hypoxia.

Pneumonia: The client's fever, increased respiratory rate, decreased oxygen saturation, and crackles in the lungs are indicative of pneumonia, particularly in the right lower lobe as evidenced by the chest X-ray.

A. Taking all drugs one hour before mealtime to prevent complications B. Limiting alcohol intake to one to two servings per day C. Avoiding taking aspirin and drugs containing aspirin D. Only take aspirin with milk or bread products E. Only taking drugs prescribed by the healthcare provider

Correct Answer is ["C","E"]

Explanation

A. Taking all drugs one hour before mealtime is not typically recommended for patients recovering from upper G.I. bleeding. Medications like proton pump inhibitors or antacids may be prescribed to reduce stomach acid, but timing varies. The patient should follow the specific instructions given by the healthcare provider regarding medication administration, especially in the context of G.I. issues.
B. Limiting alcohol intake is important for general health, but after an episode of upper G.I. bleeding, alcohol should be avoided or minimized entirely. Alcohol can irritate the stomach lining and increase the risk of further bleeding. The healthcare provider may recommend complete abstinence from alcohol during recovery.
C. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can cause irritation of the stomach lining and increase the risk of bleeding, so they should be avoided after an episode of upper G.I. bleeding. This is crucial for preventing recurrence of bleeding.
D. Taking aspirin with milk or bread does not negate its potential for irritation or bleeding risk. Patients recovering from upper G.I. bleeding should avoid aspirin entirely unless specifically directed otherwise by the healthcare provider.
E. Only taking drugs prescribed by the healthcare provider is essential. Over-the-counter medications, especially NSAIDs, should be avoided unless directed by a healthcare provider, as they can exacerbate the risk of further G.I. bleeding.

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A patient is being treated for bleeding esophageal varices with balloon tamponade. Which of the following nursing actions will the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a tracheostomy. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client has manifestations of dropdownanddropdown

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

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