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 ["0.4"]
Explanation
Volume (mL) = Desired dose (mg) / Concentration (mg/mL)
In this case:
- Desired dose = 35 mg
- Concentration = 75 mg/mL
Plugging the values into the formula:
- Volume = 35 mg / 75 mg/mL = 0.4 mL
Correct Answer is A
Explanation
A. The IV tubing for TPN should be changed every 24 hours to prevent infection, as TPN is a high-risk solution for bacterial growth due to its high glucose content. Regular changes help reduce the risk of contamination and complications such as bloodstream infections.
B. The IV site dressing should be changed at least every 48 to 72 hours (or per institutional policy) to maintain aseptic technique and minimize infection risk. Changing the dressing every 4 days may exceed this timeframe and increase the risk of infection.
C. Weighing the client is important to monitor fluid balance, but daily weighing is more typical than every other day for clients receiving TPN. This helps to assess nutritional status and detect potential fluid overload or deficit.
D. Blood glucose levels should be monitored more frequently, typically every 6 hours, because TPN can cause significant fluctuations in blood glucose. Checking every 12 hours would not be adequate for early detection of hyperglycemia or hypoglycemia.
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