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 C

Explanation

A. Green tea, while it contains some caffeine, is generally not considered a significant risk factor for the development of peptic ulcers. It may have protective effects due to its antioxidant properties, unlike substances that directly irritate the stomach lining.
B. Moderate alcohol consumption, such as a glass of wine, may irritate the stomach lining but is not a primary risk factor for peptic ulcers unless excessive drinking occurs. This would not be the most significant factor for ulcer development.
C. NSAID use is a well-established risk factor for peptic ulcers. NSAIDs inhibit the production of prostaglandins, which protect the stomach lining from acid damage. Chronic use of NSAIDs can lead to ulcer formation due to this inhibition.
D. Bulimia can lead to acid reflux or esophageal irritation, but it is not a direct risk factor for the formation of peptic ulcers. The primary risk factors for peptic ulcers include H. pylori infection and the use of NSAIDs.

A. A patient with a scheduled physical therapy session in 1 hour. B. A patient with a routine follow-up appointment for a non-urgent condition. C. A patient with altered mental status and confusion. D. A patient with moderate pleuritis and requesting pain medication.

Correct Answer is C

Explanation

A. While this patient is scheduled for a physical therapy session, it is not an urgent concern that would require immediate attention.
B. A routine follow-up appointment for a non-urgent condition can be managed at a later time and does not take priority over more acute concerns.
C. A patient with altered mental status and confusion should be assessed first. This could indicate a serious underlying issue such as infection, hypoxia, or a neurological condition. Altered mental status in any patient warrants immediate attention to prevent further complications.
D. Although the patient with pleuritis is in pain, moderate pleuritis is typically not an urgent condition, and pain management can be provided after more pressing concerns are addressed.

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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

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