A client is being treated for bleeding esophageal varices with a Sengstaken-Blakemore tube. Nursing care will include which of these approaches?
a. allowing the client to assume a position of choice
b. emptying the drainage bottle and recording output
c. periodically deflating the balloon
d. providing sips of ice water every 30 to 45 minutes
C
Esophageal varices are enlarged, twisted esophageal veins that are usually associated with chronic liver obstruction such as occurs in cirrhosis; they are asymptomatic until they rupture and hemorrhage. Medical management includes sclerotherapy or ligation; balloon tamponade is used during active bleeding. Medications may also be prescribed to prevent esophageal irritation, to control bleeding, and to control pain following sclerotherapy. Surgical treatment includes creation of a portosystemic shunt or a transjugular intrahepatic portosystemic shunt. Nursing care focuses on monitoring the client's vital signs and overall condition for evidence of bleeding, periodically deflating the balloon if a Sengstaken-Blakemore tube is used, and alleviating client anxiety.
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Medical management of a patient with status asthmaticus that supports oxygenation and ventilation include (Select all that apply.)
a. oxygen therapy. b. bronchodilators. c. corticosteroids. d. antibiotics. e. intubation and mechanical ventilation.
A 39-year-old teacher with bronchitis has been up all night with intense coughing spasms and asks the nurse "How is all this coughing related to my bronchitis?" The nurse tells the patient that a cough is initiated by what?
A) Irritation to receptors in the nasal cavity B) Irritation to receptors in the bronchi C) Irritation to receptors in the pharynx D) Irritation to receptors in the sinus cavities
Order: Eptifibatide (Integrilin)180 mcg/kg IV stat. The manufacturer recommends adding 0.7 mL of sterile water for injection to each 0.75 mg vial, yielding 0.75 mg/mL. The client weighs 185 pounds. How many milliliters will you administer?
1. 44.4 mL 2. 11.4 mL 3. 20.2 mL 4. 202.8 mL
A nurse manager is discussing medication errors with a group of nurses. Which statement by the nurses indicates the teaching was effective?
A. A nurse who observes the five rights will prevent all medication errors from occurring. B. Nurses are always liable when a medication error occurs. C. Handwritten orders are more frequently associated with medication errors than are typed orders. D. An incorrect dose (based on weight) is ordered, dispensed, and administered to a client. The administering nurse and ordering clinician would be the only parties held accountable.