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

Choice A: Weight gain is not a manifestation of left-sided heart failure. Weight gain is more likely to occur in right-sided heart failure, as the blood backs up in the systemic circulation and causes ﬂuid retention and edema in the body.

Choice B: Anorexia is not a manifestation of left-sided heart failure. Anorexia is a loss of appetite, which can have many causes, such as psychological disorders, infections, medications, or cancer. Left-sided heart failure does not directly affect appetite, but it can cause nausea, fatigue, and weakness.

Choice C: A distended abdomen is not a manifestation of left-sided heart failure. A distended abdomen is more likely to occur in right-sided heart failure, as the blood backs up in the portal vein and causes increased pressure in the liver and spleen. This can lead to hepatomegaly, splenomegaly, ascites, and varices.

Choice D: Breathlessness is a manifestation of left-sided heart failure. Breathlessness, or dyspnea, is a sensation of difficulty breathing or shortness of breath. Breathlessness occurs in left-sided heart failure, as the blood backs up in the lungs and causes pulmonary congestion and edema. This impairs gas exchange and reduces oxygen delivery to the tissues.

A. Carotid B. Popliteal C. Radial D. Apical

Correct Answer is A

Explanation

Choice A Reason: This is correct because the carotid pulse is the most accessible and reliable pulse to check during CPR for an adult client. The carotid pulse is the most accessible and reliable pulse to check during CPR for an adult client. The carotid pulse is located on the side of the neck, near the trachea. The nurse should use two fingers to palpate the carotid pulse for at least 5 seconds and no more than 10 seconds.

Choice B Reason: This is incorrect because the popliteal pulse is located behind the knee and is not easily palpable during CPR.

Choice C Reason: This is incorrect because the radial pulse is located on the wrist and may not be detectable during CPR due to low blood pressure or peripheral vasoconstriction.

Choice D Reason: This is incorrect because the apical pulse is located on the chest and requires a stethoscope to auscultate. The nurse should not interrupt chest compressions or ventilations to listen to the apical pulse during CPR.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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