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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A Reason: Assisting the RN to prepare an IV insulin infusion is not the first action that the nurse should take, as it may not be appropriate for the client's condition without knowing the blood glucose level.

Choice B Reason: Giving the client 4 oz of orange juice is not the first action that the nurse should take, as it may worsen the client's condition if the blood glucose level is high.

Choice C Reason: Checking the client's capillary blood glucose is the first action that the nurse should take, as it helps to determine if the client has hyperglycemia or hypoglycemia and guides the appropriate intervention.

Choice D Reason: Assisting the RN to administer 50% dextrose is not the first action that the nurse should take, as it may be harmful for the client if the blood glucose level is high.

A. Sharing personal hygiene items like razors B. Unprotected sexual activity C. Eating uncooked foods D. Getting a tattoo

Correct Answer is C

Explanation

Choice A Reason: Sharing personal hygiene items like razors is not a common way of spreading hepatitis A, but it may transmit hepatitis B or C, which are blood-borne infections.

Choice B Reason: Unprotected sexual activity is not a common way of spreading hepatitis A, but it may transmit hepatitis B or C, or other sexually transmitted infections.

Choice C Reason: Eating uncooked foods is a common way of spreading hepatitis A, as the virus can contaminate food or water that has been exposed to fecal matter from an infected person.

Choice D Reason: Getting a tattoo is not a common way of spreading hepatitis A, but it may transmit hepatitis B or C, or other blood-borne infections, if the equipment is not properly sterilized.

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A client diagnosed with esophageal varices has a Sengstaken-Blakemore tube. What is the most important safety intervention for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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