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 ["28"]
Explanation
Total volume (mL) Drop factor (gtt/mL) = Total drops
1000 mL 10 gtt/mL = 10,000 drops
Next, we need to determine the total number of minutes in 6 hours:
6 hours 60 minutes/hour = 360 minutes
Finally, we can calculate the drip rate:
Drip rate (gtt/min) = Total drops / Total minutes
Drip rate = 10,000 drops / 360 minutes ≈ 28 gtt/min
Correct Answer is A
Explanation
A. Reviewing electrolyte values is the first action to take, as clients with acute exacerbations of ulcerative colitis are at risk for electrolyte imbalances due to diarrhea and fluid loss. It is essential to correct any imbalances promptly to avoid complications like cardiac arrhythmias.
B. While obtaining a dietary history is important to understand the client's eating habits and trigger foods, it is not the priority when the client is experiencing an acute exacerbation. Addressing immediate physiological needs comes first.
C. Checking perianal skin integrity is important, as diarrhea and frequent bowel movements can lead to irritation or breakdown of the skin, but this is not the first priority in the acute phase of exacerbation. Managing electrolyte levels and hydration takes precedence.
D. Investigating emotional concerns is important in the holistic care of the patient, but it is not the first priority in managing an acute exacerbation of ulcerative colitis. Ensuring the client is physically stable through electrolyte management is more urgent.
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