A nurse is caring for a client who was admitted 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.
Encourage the client to consume clear liquids.
Ambulate the client four times per day.
Keep the client in a supine position.
The Correct Answer is A
Managing esophagogastric balloon tamponade requires knowledge of airway protection and mucosal integrity. Applying nursing interventions for a client with a Sengstaken-Blakemore tube involves preventing complications like aspiration and tissue necrosis while maintaining the mechanical pressure needed for hemostasis.
Choice A rationale
Frequent oral and nares care is essential because the tube causes irritation and prevents the client from swallowing saliva. Secretions accumulate in the upper airway, increasing infection risk and skin breakdown at the insertion site.
Choice B rationale
Clients with a Sengstaken-Blakemore tube must remain strictly NPO to prevent aspiration and avoid disturbing the tube. The balloon occupies the esophagus and stomach to stop variceal bleeding, making oral intake impossible and extremely dangerous.
Choice C rationale
Ambulation is contraindicated for a client with an active balloon tamponade due to the risk of tube displacement. Displacement can lead to airway obstruction if the gastric balloon migrates upward into the oropharynx or trachea.
Choice D rationale
A supine position increases the risk of aspiration and respiratory distress. The nurse should maintain the head of the bed at 30 to 45 degrees to facilitate breathing and minimize the risk of pulmonary complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Managing electrolyte imbalances in end stage renal disease requires understanding renal excretion failures. The presence of cardiac rhythm changes indicates a life threatening emergency. Immediate intervention is necessary to remove toxins and excess ions that the kidneys cannot process.
Choice A rationale
Loop diuretics are ineffective for clients with end stage renal disease because the nephrons are no longer functional. These medications cannot induce diuresis or lower serum potassium levels when the kidneys have reached the point of failure.
Choice B rationale
Similar to other loop diuretics, furosemide relies on renal blood flow and functional kidney tissue to promote fluid and electrolyte excretion. In end stage failure, this medication will not resolve the cardiac symptoms or hyperkalemia.
Choice C rationale
This is the definitive treatment for life threatening hyperkalemia in renal failure. Dialysis rapidly removes excess potassium and metabolic waste from the blood. It corrects the electrical instability in the heart caused by the high potassium levels.
Choice D rationale
Increasing fluid intake is contraindicated in end stage renal disease due to the risk of fluid volume overload. This would exacerbate the client's condition, potentially leading to pulmonary edema, hypertension, and worsening of the cardiac strain.
Correct Answer is A
Explanation
Chest tube management for pneumothorax involves monitoring for clinical complications and system patency. This scenario requires applying knowledge of respiratory emergencies, specifically recognizing signs of tension pneumothorax, which is a life threatening complication characterized by shifting of thoracic structures.
Choice A rationale
Tracheal deviation toward the unaffected side signifies a tension pneumothorax. This occurs when intrapleural pressure increases significantly, causing a mediastinal shift that compresses the heart and opposite lung, requiring immediate needle decompression or chest tube adjustment by providers.
Choice B rationale
Eyelets are the drainage holes at the end of the chest tube. If they are not visible, it indicates the tube is correctly positioned within the pleural space. Visible eyelets would suggest the tube has partially dislodged.
Choice C rationale
Crepitus, or subcutaneous emphysema, is a common finding where air leaks into subcutaneous tissues around the insertion site. While it should be monitored and documented, it generally does not require emergency provider notification unless it rapidly expands.
Choice D rationale
Intermittent bubbling in the water seal chamber during exhalation or coughing is expected in a patient with a pneumothorax. It indicates that air is successfully being evacuated from the pleural space into the drainage system.
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