A nurse is caring for a client who was admited with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?
Provide frequent oral and nares care
Keep the client in a supine position
Ambulate the client four times per day
Encourage the client to consume clear liquids
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Removing the elastic bandages is not recommended. These bandages help slow the spread of venom by compressing the lymphatic vessels. Removing them could worsen the envenomation.
Choice B: This is incorrect. The nurse should not discharge the client, as they may develop serious complications from the snake bite, such as swelling, bleeding, infection, or shock. The client should be monitored closely and treated accordingly.
Choice C: This is the correct action. Antivenom treatment is crucial for serious snake envenomation. The sooner it can be administered, the better the outcome.
Choice D: While pain management is important, it is not the priority in this situation. Antivenom takes precedence over pain medication.
Correct Answer is B
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: The radial pulse in the left arm is the correct choice because it evaluates distal circulation in the affected limb. Since the catheterization was performed through the left antecubital fossa, it is crucial to monitor blood flow further down in the arm. Palpating the radial pulse helps detect early signs of compromised perfusion, such as diminished pulse strength. Evidence-based guidelines from clinical sources highlight the importance of distal pulse assessment post-catheterization.
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: The brachial pulse in the right arm does not provide relevant information about the left arm’s vascular status post-catheterization. Since the right arm was not affected by the procedure, its pulse does not indicate possible complications in the left arm. Clinical assessment should focus on detecting perfusion issues in the limb where the catheter was inserted. Best practices recommend prioritizing the evaluation of circulation in the affected extremity.
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