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: Carvedilol is not a medication that interacts with contrast material and places the client at risk for acute kidney injury. Carvedilol is a beta-blocker that lowers blood pressure and heart rate by blocking the eﬀects of adrenaline on the heart and blood vessels. Carvedilol does not aﬀect kidney function or contrast excretion, but it can cause hypotension, bradycardia, or heart failure in some clients.

Choice B: Nitroglycerin is not a medication that interacts with contrast material and places the client at risk for acute kidney injury. Nitroglycerin is a vasodilator that relaxes the smooth muscles of the blood vessels and increases blood ﬂow to the heart. Nitroglycerin does not aﬀect kidney function or contrast excretion, but it can cause hypotension, headache, or ﬂushing in some clients.

Choice C: Atorvastatin is not a medication that interacts with contrast material and places the client at risk for acute kidney injury. Atorvastatin is a statin that lowers cholesterol levels by inhibiting an enzyme that produces cholesterol in the liver. Atorvastatin does not aﬀect kidney function or contrast excretion, but it can cause liver damage, muscle pain, or rhabdomyolysis in some clients.

Choice D: Metformin is a medication that interacts with contrast material and places the client at risk for acute kidney injury. Metformin is an oral antidiabetic drug that lowers blood glucose levels by decreasing hepatic glucose production and increasing insulin sensitivity. Metformin can accumulate in the kidneys and cause lactic acidosis, a life-threatening condition characterized by high levels of lactic acid in the blood. Contrast material can worsen kidney function and increase the risk of lactic acidosis in clients taking metformin. Therefore, metformin should be discontinued before and after the procedure as prescribed.

A. Sinus bradycardia B. Sinus tachycardia C. Atrial fibrillation D. First-degree AV block

Correct Answer is C

Explanation

Choice A Reason: This is incorrect. Sinus bradycardia is a slow and regular heart rate that originates from the sinus node. It does not cause irregular palpitations, fatigue, or dizziness, unless the heart rate is very low or the client has underlying cardiac disease.

Choice B reason: This is incorrect. Sinus tachycardia is a fast and regular heart rate that originates from the sinus node. It may cause fatigue or dizziness, but not irregular palpitations or pulse deficit.

Choice C Reason: This is correct. Atrial fibrillation is a fast and irregular heart rate that originates from multiple foci in the atria. It causes irregular palpitations, fatigue, dizziness, and pulse deficit due to ineﬀective atrial contractions and variable ventricular response.

Choice D Reason: This is incorrect. First-degree AV block is a delay in the conduction of impulses from the atria to the ventricles. It does not aﬀect the heart rate or rhythm, and does not cause any symptoms.

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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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A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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