the client being treated for esophageal varices has a sengstaken blakemore tube inserted to control the bleeding the most important assessment is for
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to:

Correct answer: C

Rationale: Regularly assessing respiratory status is crucial when a Sengstaken-Blakemore tube is inserted to control bleeding in esophageal varices.

2. Surgical management of ulcerative colitis may be performed to treat which of the following complications?

Correct answer: D

Rationale: Surgical management of ulcerative colitis may be necessary to treat complications such as bowel perforation.

3. Jerod is experiencing an acute episode of ulcerative colitis. What is the priority for this patient?

Correct answer: A

Rationale: The correct answer is to replace lost fluid and sodium. During an acute episode of ulcerative colitis, the priority is to manage the patient's fluid and electrolyte balance. This is crucial due to the potential for dehydration and electrolyte imbalances resulting from diarrhea and inflammation in the colon. Monitoring serum glucose levels (Choice B) may be important for patients on steroid therapy, but in this scenario, fluid and electrolyte balance take precedence. Restricting dietary intake of foods high in potassium (Choice C) is not a priority in the acute phase of ulcerative colitis. While noting changes in stool color and consistency (Choice D) is important for assessing the patient's gastrointestinal status, it is not the priority when managing acute ulcerative colitis.

4. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate?

Correct answer: B

Rationale: Documenting the findings is the most appropriate action as 750ml of green-brown drainage is expected after a cholecystectomy.

5. A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. The nurse should monitor the client most closely for which of the following?

Correct answer: C

Rationale: A Sengstaken-Blakemore tube is inserted into a client with a diagnosis of cirrhosis and ruptured esophageal varices. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated the client may begin to bleed again from the esophageal varices, noted by vomiting of blood.

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