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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Tympany upon chest percussion is typically associated with the presence of air, such as in cases of pneumothorax or gastric distention. It is not a typical finding in pneumonia.
B. Unequal pupils (anisocoria) are not a common symptom of pneumonia and may indicate a neurological issue rather than a respiratory infection.
C. Hypertension is not a characteristic finding in community-acquired pneumonia. Pneumonia may cause changes in blood pressure, but hypotension or normal blood pressure is more likely.
D. Confusion is a common finding in older adults with pneumonia. This can be due to factors such as hypoxia, dehydration, or infection-related changes in mental status, often referred to as "pneumonia delirium" or "acute confusion." Older adults are particularly susceptible to cognitive changes due to infection.
Correct Answer is C
Explanation
A. Encouraging coughing and deep breathing is important for promoting the clearance of respiratory secretions. However, while it aids in mobilizing secretions, it does not directly thin the mucus.
B. Frequent ambulation helps to improve overall lung function and prevent complications like pneumonia, but it does not specifically thin respiratory secretions.
C. Increasing fluid intake helps thin the respiratory secretions by providing hydration, making it easier for the body to expel mucus through coughing. Hydration is critical for reducing the viscosity of sputum, thus promoting its removal.
D. Regular use of the incentive spirometer helps prevent atelectasis and improve lung expansion but does not directly affect the thinning of respiratory secretions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.