A patient is being treated for bleeding esophageal varices with balloon tamponade. Which of the following nursing actions will the nurse include in the plan of care?
Administer anticoagulant medications.
Monitor vital signs every 4 hours.
Encourage the patient to consume a high-fiber diet.
Assist with the insertion and removal of the balloon tamponade device.
The Correct Answer is B
A. Administering anticoagulant medications is contraindicated in patients with bleeding esophageal varices. Anticoagulants could worsen bleeding and complicate the condition further. The goal in managing esophageal varices is to control the bleeding, not to increase the risk of bleeding.
B. Monitoring vital signs frequently is critical in patients with bleeding esophageal varices, as they are at risk for hypovolemic shock. Vital signs should be monitored closely to assess for signs of bleeding, hemodynamic instability, and response to interventions. Typically, more frequent monitoring (every 15 minutes initially, then every hour) is indicated, not just every 4 hours.
C. A high-fiber diet is not appropriate for patients with bleeding esophageal varices. This can increase intra-abdominal pressure and may worsen bleeding. The diet should be tailored to the patient's needs, typically involving low-residue or soft foods depending on their condition.
D. Assisting with the insertion and removal of the balloon tamponade device should be done by a skilled provider, not the nurse. The nurse's role involves monitoring for complications, ensuring proper positioning, and assessing the patient's response to treatment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. 3% sodium chloride is a hypertonic solution used to treat severe hyponatremia and should not be used as a substitute for TPN.
B. Lactated Ringer's is an isotonic solution typically used for fluid resuscitation, but it lacks the necessary components (glucose, amino acids) that are found in TPN.
C. 0.9% sodium chloride is an isotonic saline solution and can be used for hydration, but it does not provide the calories and nutrients that the client is receiving through TPN.
D. Dextrose 10% in water is the best choice in this scenario. It provides glucose for energy and can help maintain blood sugar levels until the next TPN solution is available. It is commonly used as a temporary substitute for TPN to prevent hypoglycemia.
Correct Answer is []
Explanation
Rationale
The nurse should administer a bronchodilator and prepare the client for intubation because the client is likely experiencing respiratory acidosis and respiratory distress. The nurse should then monitor for the correct placement of the ETT following intubation as well as the client's arterial blood gases to normalize.
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