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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice a) is incorrect because calcium levels are not directly affected by hemodialysis. Calcium is a mineral that is important for bone health, blood clotting, and muscle contraction. Hemodialysis does not remove calcium from the blood, but it may cause low calcium levels if the dialysate fluid has a lower concentration of calcium than the blood.
Choice b) is correct because potassium levels are decreased by hemodialysis. Potassium is an electrolyte that is essential for nerve and muscle function, especially the heart. Hemodialysis removes excess potassium from the blood, which can build up in people with kidney failure and cause irregular heartbeats, muscle weakness, or even cardiac arrest.
Choice c) is incorrect because protein levels are not decreased by hemodialysis. Protein is a macromolecule that is composed of amino acids and performs various functions in the body, such as building and repairing tissues, transporting substances, and regulating processes. Hemodialysis does not remove protein from the blood, but it may cause low protein levels if the client has a poor diet or loses protein through other means, such as urine or wounds.
Choice d) is incorrect because RBC count is not decreased by hemodialysis. RBCs are red blood cells that carry oxygen throughout the body. Hemodialysis does not remove RBCs from the blood, but it may cause low RBC count if the client has anemia, which is a common complication of kidney failure. Anemia can be caused by reduced production of erythropoietin (a hormone that stimulates RBC production), iron deficiency, or blood loss.
Correct Answer is A
Explanation
Choice A: Provide frequent oral and nares care is the correct action for the nurse to take. Oral and nares care can help prevent infection, dryness, and irritation of the mucous membranes, which can be damaged by the pressure and friction of the tube. The nurse should also monitor the tube position, secure it with tape, and keep scissors at the bedside in case of emergency deflation.
Choice B: Keep the client in a supine position is not the correct action for the nurse to take. The supine position can increase the risk of aspiration, regurgitation, and gastric distension, which can worsen the bleeding and compromise the airway. The nurse should elevate the head of the bed to at least 30 degrees and use a semi-Fowler's or high-Fowler's position.
Choice C: Ambulating the client four times per day is not the correct action for the nurse to take. Ambulation can increase abdominal pressure and dislodge the tube, which can cause bleeding and perforation. The nurse should keep the client on bed rest and use passive range-of-motion exercises to prevent complications such as thromboembolism and muscle atrophy.
Choice D: Encouraging the client to consume clear liquids is not the correct action for the nurse to take. Clear liquids can increase gastric volume and acidity, which can aggravate the bleeding and interfere with hemostasis. The nurse should maintain a nothing-by-mouth status and provide intravenous fluids and nutrition as prescribed.
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