A client is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which nursing intervention is the priority?
a. Keep the client sedated to prevent tube dislodgement.
b. Maintain balloon pressure at between 15 and 20 mm Hg.
c. Irrigate the gastric lumen with normal sa-line.
d. Maintain the client's airway.
D
Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration and occlusion of the airway. The client usually is intubated and mechanically ventilated during this procedure. The other interventions are not a priority over airway.
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Shortly after delivery, the nurse assists the mother to initiate breastfeeding her newborn. What is the rationale for this intervention?
a. Infants are frequently alert during the first period of reactivity. b. Breastfeeding helps the infant make the transition to extrauterine life. c. Infants need nourishment as soon as possible after birth. d. Infants will learn how to breastfeed correctly if introduced to the breast immediately.
Which laboratory test results would the nurse check to determine the effectiveness of an antiretroviral medication in an HIV-infected patient?
A) Western blot B) HIV RNA C) HIV ELISA D) Phenotypic resistance analyses
MC The nurse is planning a program to encourage exercise among high school students. Teachers and parents will be involved in implementing the program. The activity that best describes the third level of acceptance of this health care program is
A. Marketing the program to the high school students. B. Convincing the principal of the benefits of the program. C. Encouraging parents to promote the program. D. Meeting with the teachers to explain the program.
Mr. Turner is a 43-year-old patient who presents for a yearly physical examination. On exam you note balanitis associated with phimosis. Which individual is this most likely to occur in?
A. Newborn male infants B. Diabetic men C. Uncircumcised men D. Men exposed to radiation