A client diagnosed with esophageal varices has a Sengstaken-Blakemore tube. What is the most important safety intervention for this client?
Keeping scissors at the bedside
Providing good mouth care
Deflating the balloon on a regular basis
Monitoring IV fluid intake
The Correct Answer is A
Choice A Reason: Keeping scissors at the bedside is the most important safety intervention for this client, as it allows for quick removal of the tube in case of airway obstruction or bleeding.
Choice B Reason: Providing good mouth care is an important intervention for this client, but it is not the most important, as it helps to prevent oral infections and discomfort.
Choice C Reason: Deflating the balloon on a regular basis is not an appropriate intervention for this client, as it may cause bleeding or displacement of the tube.
Choice D Reason: Monitoring IV fluid intake is an important intervention for this client, but it is not the most important, as it helps to prevent fluid overload or dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Cushing's is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excess cortisol and aldosterone production.
Choice B Reason: Diabetes insipidus is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excessive water loss and dilution of blood.
Choice C Reason: Addison's is an expected health problem in a client with high potassium level, as it causes high potassium level due to insufficient cortisol and aldosterone production.
Choice D Reason: Diarrhea is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excessive fluid and electrolyte loss.
Correct Answer is D
Explanation
Choice A Reason: Anorexia is not a symptom of hypoglycemia, but it may indicate a loss of appetite due to other causes such as nausea, infection, or depression.
Choice B Reason: Warm skin is not a symptom of hypoglycemia, but it may indicate a fever, inflammation, or infection.
Choice C Reason: Fruity breath is not a symptom of hypoglycemia, but it may indicate ketoacidosis, which is a serious complication of hyperglycemia.
Choice D Reason: Nervousness is a symptom of hypoglycemia, as the low blood glucose level affects the brain and causes anxiety, irritability, confusion, and tremors.
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