A nurse is caring for a client who has bleeding esophageal varices and is being treated with a Sengstaken-Blakemore tube. Which of the following actions should the nurse perform?

Deﬂate the balloons for 5 min every 2 hr to prevent tissue necrosis.

Keep the head of the bed ﬂat at all times to prevent the development of shock.

Maintain constant observation while the balloons are inﬂated.

Suction the tube every 2 hr and as needed to maintain patency.

Answer and Explanation

The Correct Answer is C

Choice A Reason: This is incorrect. The balloons should not be deﬂated without a physician's order, as this can cause rebleeding or aspiration.

Choice B Reason: This is incorrect. The head of the bed should be elevated to 30 to 45 degrees to reduce pressure on the balloons and prevent gastric reﬂux.

Choice C Reason: This is correct. The nurse should monitor the client closely for signs of complications, such as airway obstruction, aspiration, or balloon rupture. The nurse should also keep scissors at the bedside to cut the tube and release the balloons in case of an emergency.

Choice D Reason: This is incorrect. The tube should not be suctioned, as this can damage the mucosa and cause bleeding. The nurse should only aspirate gastric contents through the gastric lumen to decompress the stomach.

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Correct Answer is D

Explanation

The correct answer is D. Blood pressure 115/68 mm Hg.

Choice A reason: Heart rate 180/min is incorrect because, although an increased heart rate is a compensatory mechanism, a rate of 180/min is excessively high and suggests a more severe stage of shock or other cardiac issues.

Choice B reason: Mottled skin is incorrect as it indicates poor perfusion seen in decompensated shock, where organ dysfunction begins to manifest, not in the compensatory stage.

Choice C reason: Hypokalemia, or low potassium levels, is incorrect because electrolyte imbalances are not typically a finding in the compensatory stage of shock. Normal potassium levels range from 3.5 to 5.0 mEq/L.

Choice D reason: Blood pressure 115/68 mm Hg is correct because it falls within the normal blood pressure range, which the body strives to maintain during the compensatory stage of shock through various mechanisms.

A. Radial pulse in the right arm B. Radial pulse in the left arm C. Brachial pulse in the left arm D. Brachial pulse in the right arm

Correct Answer is D

Explanation

The correct answer is: d. Brachial pulse in the right arm.

Choice A reason: Palpating the radial pulse in the right arm is not the most appropriate choice following a cardiac catheterization with a left antecubital insertion site. While it is contralateral to the insertion site, the brachial pulse is preferred over the radial pulse for assessing circulation in the arm, as it is more proximal and can provide a better indication of arterial flow from the catheterization site.

Choice B reason: Palpating the radial pulse in the left arm, which is ipsilateral to the insertion site, is not recommended. This is because the radial pulse may be diminished or absent due to arterial occlusion or spasm caused by the catheterization procedure.

Choice C reason: Palpating the brachial pulse in the left arm is also not recommended. Since the catheterization was performed on the left side, there is a risk of arterial occlusion or spasm, which could affect the accuracy of the pulse assessment in the left arm.

Choice D reason: Palpating the brachial pulse in the right arm is the correct action. It is contralateral to the insertion site and unaffected by the procedure, providing a reliable assessment of the client’s circulatory status post-cardiac catheterization.

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A nurse is caring for a client who has bleeding esophageal varices and is being treated with a Sengstaken-Blakemore tube. Which of the following actions should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?

Correct Answer is D

Explanation

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