The client with esophageal varices was admitted with hypovolemic shock secondary to upper gastrointestinal bleed. Which intervention is not appropriate for this client?

Administer lactulose as prescribed for the client with liver failure.

Ensure that the balloon of an esophagogastric balloon tube is in place no longer than 12 hours

Closely monitor respiratory and neurological status.

Prepare for emergent surgery

Answer and Explanation

The Correct Answer is A

Rationale:

A. Lactulose is used to treat hepatic encephalopathy by reducing ammonia levels in clients with liver failure. However, in a client admitted with hypovolemic shock from active upper gastrointestinal bleeding, the priority is stabilizing circulation and airway, not administering medications for encephalopathy. Lactulose can worsen dehydration and diarrhea, potentially exacerbating hypovolemia, which is dangerous in a client already in shock. Therefore, this is not an appropriate immediate intervention.

B. For clients with esophageal varices, a balloon tamponade (e.g., Sengstaken-Blakemore tube) may be used to control bleeding. Monitoring balloon placement and duration is critical to prevent tissue necrosis, airway obstruction, or further complications. This is an appropriate intervention.

C. Airway management is critical in a client with an esophagogastric balloon tube and hypovolemic shock. Monitoring respiratory status ensures early detection of airway compromise, while neurological monitoring helps detect hypoperfusion or hypoxia. This is an appropriate and high-priority intervention.

D. If bleeding cannot be controlled with medical therapy or balloon tamponade, emergent surgical or interventional radiology procedures (e.g., variceal ligation or shunt procedures) may be necessary. Preparing for surgery is appropriate in severe, uncontrolled bleeding.

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Correct Answer is C

Explanation

Rationale:

A. Obtaining a type and crossmatch is necessary for blood transfusion in variceal bleeding, but this is not the immediate first action. Stabilizing the airway takes precedence over preparing for transfusion.

B. Inserting two large-bore IV lines is important for rapid fluid or blood replacement, but it comes after ensuring the airway is clear and the client can oxygenate effectively. IV access alone does not prevent hypoxia.

C. Suctioning the airway is the first priority. Clients with variceal bleeding are at risk for vomiting large amounts of blood, which can obstruct the airway and cause aspiration or hypoxemia. According to the ABC (Airway, Breathing, Circulation) priority framework, maintaining a patent airway is always the first action in emergencies.

D. Preparing the client for endoscopy is essential for definitive treatment of variceal bleeding, but this is not the immediate priority. The client must first be stabilized—airway maintained, breathing supported, and circulation ensured—before diagnostic or therapeutic procedures.

Correct Answer is ["14"]

Explanation

Step 1: Calculate the ordered dose in units/hr
Dose (units/hr) = 18 units/kg/hr × 80 kg
Dose = 1,440 units/hr

Step 2: Determine the concentration of the IV solution
25,000 units in 250 mL
Concentration = 25,000 ÷ 250
Concentration = 100 units/mL

Step 3: Calculate mL/hr
mL/hr = Dose ÷ Concentration
mL/hr = 1,440 ÷ 100
mL/hr = 14.4 mL/hr

Step 4: Round to the nearest whole number
14.4 = 14 mL/hr

Final Answer: 14 mL/hr

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The client with esophageal varices was admitted with hypovolemic shock secondary to upper gastrointestinal bleed. Which intervention is not appropriate for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse cares for a client with cirrhosis who is experiencing variceal bleeding. What should the nurse do first?

Correct Answer is C

Explanation

The nurse prepares to administer 18 units/kg/hr of heparin to client weighing 80 kg. The heparin is supplied in a concentration of 25,000 units in 250 mL of normal saline. How many mL/hr would the nurse deliver the heparin? Round to a whole number.

Correct Answer is ["14"]

Explanation

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