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 B
Explanation
Choice a) is incorrect because troponin is not an enzyme, but a protein. Enzymes are molecules that speed up chemical reactions in the body. Troponin does not have this function.
Choice b) is correct because troponin is a protein that binds to calcium and regulates the contraction of heart muscle fibers. When the heart muscle is injured, such as in a myocardial infarction, troponin leaks into the bloodstream and can be detected by a blood test. The higher the level of troponin, the more severe the damage to the heart.
Choice c) is incorrect because troponin does not help transport oxygen throughout the body. That function is performed by hemoglobin, which is a protein found in red blood cells.
Choice d) is incorrect because troponin is not a lipid, but a protein. Lipids are fats that are used for energy storage and cell membrane formation. Troponin does not have these roles.
Correct Answer is D
Explanation
Choice A reason: Vesicles on the skin are not typical of inhalation anthrax; instead, they are more associated with cutaneous anthrax, which presents as papules that progress to vesicles and then black eschars.
Choice B reason: Respiratory failure can occur later in the course of inhalation anthrax, but it is not an early finding. It usually develops after the initial phase of nonspecific symptoms when the illness progresses to severe respiratory distress and shock.
Choice C reason: Sloughing of skin is not characteristic of inhalation anthrax. Similar to vesicles, skin sloughing may be associated with severe cutaneous infections or other dermatologic conditions, not the respiratory form of anthrax.
Choice D reason: Flu-like symptoms, such as fever, cough, malaise, muscle aches, and mild chest discomfort, are the initial and most indicative early findings of inhalation anthrax. These nonspecific symptoms often appear within several days after exposure before progressing to severe respiratory compromise.
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