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.
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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Related Questions
Correct Answer is A
Explanation
A. A hiatal hernia can increase the risk of gastroesophageal reflux disease (GERD) because the hernia can cause the lower esophageal sphincter to malfunction, leading to the backflow of stomach acid into the esophagus. This increases the risk of reflux symptoms, such as heartburn and regurgitation.
B. There is no direct link between a hiatal hernia and an increased risk for stomach cancer. While long-term GERD can contribute to other esophageal issues, such as Barrett’s esophagus, it does not directly cause stomach cancer.
C. A hiatal hernia does not increase the risk of intestinal cancer. Its primary association is with GERD and related complications.
D. A hiatal hernia is not associated with an increased risk for lung disease. However, severe GERD symptoms can cause respiratory issues such as aspiration pneumonia, but this is not the same as directly increasing the risk of lung disease.
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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