Nokea
Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the client appears to be having difficulty breathing. The nurse's first action should be to:
- A. Remove the tube.
- B. Deflate the esophageal portion of the tube.
- C. Determine whether the tube is obstructing the airway.
- D. Increase the oxygen flow rate.
Correct Answer: C
Rationale: Difficulty breathing may indicate airway obstruction by the Sengstaken-Blakemore tube, so assessing this is the priority action.
You may also like to solve these questions
A client is being treated for severe pediculosis. The nurse should instruct the client to treat the problem in the eyebrows and eyelashes by:
- A. Applying petroleum jelly to lashes and brows three to four times a day.
- B. Applying a pediculicide with a cotton-tipped swab three to four times a day.
- C. Applying lindane ointment to the lashes and eyebrows three times a day.
- D. Applying bacitracin ointment to the lashes and brows three times a day.
Correct Answer: A
Rationale: Petroleum jelly smothers lice in the eyebrows and eyelashes, a safe and effective treatment for this sensitive area, unlike pediculicides or antibiotics.
The nurse is assessing a client with a history of heart failure who is receiving a 500-mL I.V. bolus of 0.9% normal saline. To evaluate the client's response to the treatment, the nurse should especially monitor the client for which of the following?
- A. Hypotension.
- B. Increased urine output.
- C. Crackles in the lungs.
- D. Dry mucous membranes.
Correct Answer: C
Rationale: In heart failure, fluid boluses can lead to pulmonary edema, so monitoring for lung crackles is critical to detect fluid overload.
A client is suspected of having a slow gastrointestinal bleed. The nurse should evaluate the client for which sign or symptom?
- A. Increased pulse.
- B. Nausea.
- C. Tarry stools.
- D. Abdominal cramps.
Correct Answer: C
Rationale: Tarry stools are a hallmark sign of a slow gastrointestinal bleed due to digested blood.
The nurse is preparing to administer insulin to a client with type 2 diabetes. Which site is most appropriate for subcutaneous injection?
- A. Deltoid muscle.
- B. Lower back.
- C. Abdomen.
- D. Upper thigh.
Correct Answer: C
Rationale: The abdomen provides consistent absorption for subcutaneous insulin due to its stable subcutaneous tissue and is a preferred site.
The nurse is caring for a client with a history of venous insufficiency. Which of the following interventions is most appropriate?
- A. Encourage prolonged standing.
- B. Apply compression stockings.
- C. Keep the legs in a dependent position.
- D. Limit fluid intake.
Correct Answer: B
Rationale: Compression stockings improve venous return and reduce swelling in venous insufficiency.