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 B
Explanation
Choice A Reason: Telling the client to expect a decrease in urine output is not an appropriate intervention for a client who has urolithiasis, as it may indicate dehydration, obstruction, or infection.
Choice B Reason: Encouraging the client to drink 3 L of fluids per day is an appropriate intervention for a client who has urolithiasis, as it helps to flush out stones, prevent new stone formation, and reduce urinary concentration.
Choice C Reason: Providing the client with a high protein diet is not an appropriate intervention for a client who has urolithiasis, as it may increase uric acid and calcium excretion and promote stone formation.
Choice D Reason: Maintaining the client on bed rest is not an appropriate intervention for a client who has urolithiasis, as it may decrease renal perfusion and increase urinary stasis.
Correct Answer is B
Explanation
Choice A Reason: Encouraging the client to cough and deep breathe every two hours, with her neck in a flexed position, is not a priority for a client after a total thyroidectomy, as it may increase the risk of bleeding or damage to the surgical site.
Choice B Reason: Maintaining the client in a Fowler's position, with head neutral supported by pillows, is a priority for a client after a total thyroidectomy, as it helps to reduce swelling and edema, prevent airway obstruction, and promote venous drainage.
Choice C Reason: Maintaining the client in a supine position, with sandbags placed on either side of her head and neck, is not a priority for a client after a total thyroidectomy, as it may impair breathing and circulation, increase pressure on the surgical site, and cause neck stiffness.
Choice D Reason: Encouraging the client to turn head side to side, to promote drainage of oral secretions, is not a priority for a client after a total thyroidectomy, as it may cause pain and discomfort, disrupt the sutures or drains, and increase the risk of infection.
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