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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Related Questions
Correct Answer is D
Explanation
A. While obesity can contribute to various health issues, it is not a direct cause of esophageal varices.
B. Smoking is harmful to overall health, but it is not specifically known to cause esophageal varices.
C. High blood pressure, especially systemic hypertension, is not a direct cause of esophageal varices. However, portal hypertension, which can be caused by liver disease, is the main factor in the development of esophageal varices.
D. Chronic liver disease, particularly cirrhosis, leads to portal hypertension, which in turn causes the veins in the esophagus to become engorged and prone to bleeding, resulting in esophageal varices. This is the most appropriate cause for esophageal varices.
Correct Answer is B
Explanation
A. While assessing sputum is important to determine its color, consistency, and amount, it is not the priority before performing percussion, vibration, and postural drainage. The nurse should first assess the patient's overall respiratory status.
B. Assessing pulse and respirations is the first step in ensuring the patient's baseline respiratory status is stable before performing respiratory therapies. This allows the nurse to detect any signs of distress or abnormal respiratory patterns, which could indicate the need for further intervention before the procedure.
C. Auscultating lung fields is important for evaluating the effectiveness of the percussion and drainage procedure, but the initial assessment should include vital signs, such as pulse and respirations, to ensure the patient is stable.
D. Instructing the patient to slowly exhale with pursed lips is a helpful technique for managing respiratory distress, but it is not the first priority before conducting percussion or postural drainage. The nurse should first assess vital signs.
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