A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse’s priority?

Elevate the client’s feet.

Administer a unit of packed RBCs.

Initiate a dopamine IV infusion for the client.

Increase the client’s IV ﬂuid rate.

Answer and Explanation

The Correct Answer is D

Choice a) is incorrect because elevating the client’s feet is not the priority action for a hypotensive client. Elevating the client’s feet may help increase the venous return to the heart, but it may also compromise the respiratory status of a client who has esophageal varices and is at risk of aspiration.

Choice b) is incorrect because administering a unit of packed RBCs is not the priority action for a hypotensive client. Administering a unit of packed RBCs may help increase the oxygen-carrying capacity of the blood, but it may also increase the blood viscosity and pressure, which can worsen the bleeding from the esophageal varices.

Choice c) is incorrect because initiating a dopamine IV infusion for the client is not the priority action for a hypotensive client. Initiating a dopamine IV infusion may help increase the blood pressure and cardiac output, but it may also cause vasoconstriction and tachycardia, which can increase the risk of hemorrhage and arrhythmias.

Choice d) is correct because increasing the client’s IV ﬂuid rate is the priority action for a hypotensive client. Increasing the client’s IV ﬂuid rate may help restore the intravascular volume and perfusion, which can prevent shock and organ damage. Increasing the client’s IV ﬂuid rate may also dilute the blood and reduce its viscosity and pressure, which can decrease the bleeding from the esophageal varices.

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Correct Answer is C

Explanation

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.

A. Copies of insurance cards B. Whistle C. Antibiotics D. Household bleach E. Pencil and paper

Correct Answer is ["A","B","D","E"]

Explanation

Choice a) is correct because copies of insurance cards can help clients access medical care and claim compensation in case of a disaster. Insurance cards can also serve as a form of identification if other documents are lost or damaged.

Choice b) is correct because a whistle can help clients signal for help or locate each other in case of an emergency. A whistle can also deter potential atackers or wild animals.

Choice c) is incorrect because antibiotics are not recommended to be included in a disaster readiness supply kit or “go bag”. Antibiotics are prescription drugs that should only be used under the guidance of a health care provider. Using antibiotics without proper indication, dosage, or duration can cause adverse eﬀects, such as allergic reactions, resistance, or superinfection.

Choice d) is correct because household bleach can be used to disinfect water, surfaces, or wounds in case of a disaster. Household bleach can also be used to create chlorine gas, which can be used as a weapon or a deterrent.

Choice e) is correct because pencil and paper can be used to write down important information, such as contact numbers, medical history, or evacuation plans. Pencil and paper can also be used to communicate with others, especially if there is no access to phone or internet services.

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A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A community health nurse is providing a community education program about disaster preparedness. Which of the following should the nurse recommend that clients include in their family’s disaster readiness supply kit or “go bag”? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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