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 ["A","C","E"]

Explanation

Choice A Reason: History of alcohol abuse is an additional information that the nurse should obtain from this client, as it may indicate liver damage or cirrhosis, which can cause clay-colored stool due to reduced bile production or flow.

Choice B Reason: Intolerance to fatty foods is not an additional information that the nurse should obtain from this client, as it does not relate to clay-colored stool, but it may indicate gallbladder disease or malabsorption.

Choice C Reason: Pain in the RUQ radiating to the shoulder is an additional information that the nurse should obtain from this client, as it may indicate gallstone obstruction or inflammation, which can cause clay-colored stool due to blocked bile ducts.

Choice D Reason: Pain in the McBurney's point is not an additional information that the nurse should obtain from this client, as it does not relate to clay-colored stool, but it may indicate appendicitis or diverticulitis.

Choice E Reason: Bleeding ulcer is an additional information that the nurse should obtain from this client, as it may indicate upper gastrointestinal bleeding, which can cause clay-colored stool due to digested blood.

A. Black cohosh B. Cranberry juice C. Saw palmetto D. Echinacea

Correct Answer is B

Explanation

Choice A Reason: Black cohosh is not an herbal supplement that can help prevent UTIs, but it may be used for menopausal symptoms such as hot flashes, night sweats, or mood swings.

Choice B Reason: Cranberry juice is an herbal supplement that can help prevent UTIs, as it may inhibit bacterial adhesion to the urinary tract and lower urine pH.

Choice C Reason: Saw palmetto is not an herbal supplement that can help prevent UTIs, but it may be used for benign prostatic hyperplasia (BPH) symptoms such as urinary frequency, urgency, or hesitancy.

Choice D Reason: Echinacea is not an herbal supplement that can help prevent UTIs, but it may be used for immune system support or wound healing.

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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

A client's stool is clay in color. What additional information should the nurse obtain from this client? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

A nurse is reinforcing teaching with a client who has frequent urinary tract infections (UTIs). The nurse should identify that the client can use which of the following herbal supplements to help prevent UTIs?

Correct Answer is B

Explanation

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following findings should the nurse expect?

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I can help you with formatting and editing the text. Here are the edited texts: Text 1: A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula?