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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Free Nursing Study Resources

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

Explanation

A. Serum phosphorus is crucial to monitor in patients at risk for refeeding syndrome. Hypophosphatemia is a key sign of the syndrome and can lead to severe complications, such as respiratory failure and cardiac arrhythmias.
B. Serum blood glucose levels are important to monitor, especially since refeeding syndrome can cause rapid shifts in glucose metabolism. However, it is not a primary test to diagnose refeeding syndrome. Blood glucose monitoring will be part of the overall management, but not the core test for the syndrome.
C. Serum calcium should be monitored because it can also decrease in refeeding syndrome due to shifts in phosphate and magnesium levels, which may affect calcium metabolism.
D. Serum potassium is essential to monitor because hypokalemia often occurs in refeeding syndrome as the body shifts electrolytes into cells. This can cause muscle weakness, arrhythmias, and other serious complications.
E. Serum magnesium is also important to check, as hypomagnesemia is commonly seen in refeeding syndrome and can contribute to neurological and cardiac symptoms.

A. "Strictureplasty is a non-surgical procedure that uses medications to treat strictures." B. "Strictureplasty is a procedure used to remove strictures in the gastrointestinal tract." C. "Strictureplasty is a surgical technique used to repair fractures in bones." D. "Strictureplasty is commonly performed in the treatment of Crohn's disease."

Correct Answer is D

Explanation

A. Strictureplasty is a surgical procedure, not a non-surgical procedure. It is used to treat strictures by widening them, typically in the gastrointestinal tract.
B. Strictureplasty does not remove strictures but rather works to widen or repair the narrowed areas, allowing for improved passage through the affected part of the gastrointestinal tract.
C. Strictureplasty is not used to repair fractures in bones. It is specifically used in the gastrointestinal system to treat strictures.
D. Strictureplasty is commonly performed in the treatment of Crohn's disease, particularly in cases where the disease causes strictures in the intestines. It is a procedure that can help maintain the integrity of the intestine by widening narrowed areas without the need for resection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with anorexia nervosa shows signs of malnutrition and is prescribed parenteral nutrition. If the client develops refeeding syndrome, what laboratory tests does the nurse expect the healthcare provider to order? (Select all that apply.)

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

Explanation

Which of the following statements about strictureplasty is correct?

Correct Answer is D

Explanation

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