The client with esophageal varices has a Sengstaken-Blakemore tube in place for esophageal tamponade. As a measure to prevent aspiration of saliva, the nurse would
a. assist the client to cough and spit saliva into an emesis basin.
b. completely deflate the esophageal balloon every 30 minutes.
c. remove saliva through the fourth lumen.
d. suction saliva accumulation with a nasogastric tube.
D
Because the Sengstaken-Blakemore tube does not have a fourth lumen, the saliva should be suc-tioned via a nasogastric tube from the top of the esophageal balloon.
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The nurse manager is consulting with a certified nurse-midwife about a client. What is the role of the CNM? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Be prepared to manage independently the care of women at low risk for complications during pregnancy and birth. 2. Give primary care for high-risk clients who are in hospital settings. 3. Give primary care for healthy newborns. 4. Obtain a physician consultation for any technical procedures at delivery. 5. Be educated in two disciplines of nursing.
The nurse walks in to find the client crying after the physician informed her of her diagnosis of human papilloma virus (HPV). Which statement by the nurse conveys an attitude of acceptance toward the client with a sexually transmitted infection?
1. "Don't worry about it. In a few weeks, with treatment, the lesions will disappear." 2. "You seem upset. I'll get the doctor." 3. "You seem upset. Can I help answer any questions?" 4. "I think you need to see a therapist."
A nurse assesses the respiratory functioning of a patient in a halo vest for alterations. What common complication associated with spinal cord injury should be monitored for this patient?
A) Pneumonia B) Bronchial infection C) Pulmonary embolus D) Hypoxia
The nurse instructs new mothers about illness prevention when the nurse tells the patients to be certain that their newborns are
A) Given massages B) Mentally stimulated C) Positioned prone for sleep D) Immunized on schedule