Treatment for a client with bleeding esophageal varices has been unsuccessful and the physician decides to insert a Sengstaken-Blakemore tube. The nurse brings which of the following items to the bedside so that it is available at all times?
1. An obturator
2. A Kelly clamp
3. An irrigation set
4. A pair of scissors
4
Rationale: When the client has a Sengstaken-Blakemore tube inserted, a pair of scissors must be kept at the client's bedside at all times. The client must be observed for sudden respiratory dis-tress, which occurs if the gastric balloon ruptures, moving the entire tube upward. If this occurs, all balloon lumens are cut and the tube is removed. An obturator and Kelly clamp would be kept at the bedside of a client with a tracheostomy. An irrigation set may be kept at the bedside but is not the priority item.
You might also like to view...
Mr. Hernandez has class IV heart failure and likes to have a glass of beer with his dinner. The nurse explains that
A) red wine will decrease his risk for coronary disease and he should switch to that. B) white wine will not affect his blood pressure and is a better choice. C) alcohol is a cardiac depressant and is contraindicated in his condition. D) one drink a day won't hurt him and he should enjoy his beer.
A nurse manager and a staff nurse are in conflict. The nursing supervisor has decided to use mediation to arrive at a solution
The supervisor should be most concerned about which person's level of comfort when choosing a place for the mediation meeting? 1. The manager 2. The staff nurse 3. The supervisor 4. There should be equal concern for all participants.
The nurse educator is teaching a group of teens and 20-year-olds reproductive health care. When several of the women bring up douching, what is the best response the nurse could make?
1. "One should always douche after having intercourse." 2. "When douching, use force putting them in and get the solution up high." 3. "It is a good idea to douche before intercourse so the area is clean for the sperm." 4. "Douching is unnecessary because the lining of the vagina has numerous glands that provide natural cleansing."
A 3-year-old has been in the hospital for a week
The child's mother has been rooming in, but other family responsibilities require that she go back to the family home for a few days. The child has been inconsolable for the past 24 hours, but now the child is lying quietly in bed sucking her thumb. What should the nurse say to this child? A) "Are you feeling sad? Your mom didn't want to leave, but she will be back after two more breakfasts." B) "I'm glad you're feeling better. You must be tired from all that crying." C) "Do you miss your mom? Your sister missed her, too, so she had to go home to visit for a few days." D) "Should I read a story to you?"