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 A

Explanation

A. Brushing the client's teeth with a suction toothbrush every 12 hours is a key intervention to reduce the risk of ventilator-associated pneumonia (VAP). Oral hygiene helps to decrease the accumulation of bacteria in the mouth, which could potentially be aspirated into the lungs and cause infection. This should be done more frequently, often every 4–6 hours, to reduce bacterial colonization.
B. Providing humidity to the ventilator tubing is necessary to maintain adequate moisture and prevent airway dryness, but it does not directly reduce the risk of VAP. Oral care and head-of-bed positioning are more crucial in preventing infection.
C. The head of the client's bed should be kept elevated, not flat, to reduce the risk of aspiration, which can lead to VAP. Keeping the head of the bed at a 30–45 degree angle is recommended.
D. Turning the client every 4 hours is important for preventing pressure ulcers and promoting circulation but is not the most effective intervention for reducing the risk of VAP. Frequent oral care and appropriate positioning are more important.

A. Night sweats B. Narrowed pulse pressure C. Confusion D. Bradycardia

Correct Answer is C

Explanation

A. Night sweats are more commonly associated with conditions like tuberculosis or certain cancers, rather than pneumonia, although they could occasionally be seen in severe pneumonia.
B. Narrowed pulse pressure is not a typical sign of pneumonia and is more indicative of conditions such as shock or heart failure.
C. Confusion is a classic and often overlooked symptom of pneumonia in older adults. Pneumonia in this population can present with altered mental status or confusion rather than typical respiratory symptoms like cough and fever.
D. Bradycardia is not a typical finding in pneumonia. In fact, tachycardia (an increased heart rate) is more commonly seen as the body tries to compensate for the infection.

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