Nokea
The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to:
- A. Check that the hemostat is on the bedside
- B. Monitor IV fluids for the shift
- C. Regularly assess respiratory status
- D. Check that the balloon is deflated on a regular basis
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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If a gastric acid perforates, which of the following actions should not be included in the immediate management of the client?
- A. Blood replacement
- B. Antacid administration
- C. Nasogastric tube suction
- D. Fluid and electrolyte replacement
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client with ascites is scheduled for a paracentesis. The nurse is assisting the physician in performing the procedure. Which of the following positions will the nurse assist the client to assume for this procedure?
- A. Supine
- B. Left side-lying
- C. Right side-lying
- D. Upright position.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
While caring for a client with peptic ulcer disease, the client reports that he has been nauseated most of the day and is now feeling lightheaded and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take?
- A. Administering an antacid hourly until nausea subsides.
- B. Monitoring the client's vital signs
- C. Notifying the family and friends of the client's symptoms
- D. Initiating oxygen therapy
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate?
- A. Notify the physician
- B. Document the findings
- C. Irrigate the T-tube
- D. Clamp the T-tube
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following measures should the nurse focus on for the client with esophageal varices?
- A. Recognizing hemorrhage
- B. Controlling blood pressure
- C. Encouraging nutritional intake
- D. Teaching the client about varices
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.