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 B
Explanation
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.
Correct Answer is D
Explanation
A. Sleeping on the stomach is not recommended for patients with GERD because it can increase pressure on the stomach, promoting acid reflux.
B. Lying on the right side can actually worsen GERD symptoms because it allows acid to flow more easily into the esophagus from the stomach, due to the positioning of the stomach and esophagus.
C. Sleeping on the back with the head flat does not provide sufficient elevation to prevent acid reflux, which can lead to symptoms worsening during the night.
D. Sleeping on the left side helps reduce the likelihood of acid reflux. This position prevents the stomach's contents from moving up into the esophagus, making it the most effective sleeping position for GERD.
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