The nurse is caring for a client with stable esophageal varices. Which of the following actions is most important?
Maintain a patent airway and prevent aspiration
Monitor the effects of ant-hypertensive medications
Prepare the client for immediate portal shunting surgery
Perform fecal occult testing on all stools
The Correct Answer is B
A. Maintain a patent airway and prevent aspiration: While maintaining a patent airway is always important, esophageal varices do not typically cause aspiration unless they rupture. This choice would be a priority in an acute bleed, not in a stable client.
B. Monitor the effects of antihypertensive medications: Beta-blockers (e.g., propranolol) are commonly prescribed to reduce portal hypertension, preventing variceal rupture. Monitoring the effects of these medications is crucial in maintaining hemodynamic stability.
C. Prepare the client for immediate portal shunting surgery: Surgical shunting is considered for refractory cases with severe, recurrent bleeding. A client with stable varices does not require immediate surgery.
D. Perform fecal occult testing on all stools: Esophageal varices cause upper GI bleeding, which manifests as hematemesis or melena, not occult blood in the stool.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["45"]
Explanation
30g x 10g ×15ml=45ml
Correct Answer is B
Explanation
A. Weight loss and malnutrition: IBS does not typically cause weight loss or malnutrition. If a client experiences these symptoms, further evaluation is needed to rule out other conditions such as inflammatory bowel disease (IBD) or malignancy.
B. Alteration between constipation and diarrhea: IBS is characterized by a change in bowel habits, which may include alternating episodes of constipation and diarrhea. This is the correct answer.
C. Severe rectal bleeding: IBS does not cause rectal bleeding. If present, conditions such as hemorrhoids, IBD, or colorectal cancer should be considered.
D. Fever and elevated white blood cell count: IBS does not cause systemic inflammation. Fever and leukocytosis are more indicative of infections or inflammatory disorders like ulcerative colitis or Crohn's disease.
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