Author Question: A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an ... (Read 39 times)

mikaylakyoung · **on:** Jun 25, 2018

A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first?

a. Sedate the client to prevent tube dislodgement.
b. Maintain balloon pressure at 15 and 20 mm Hg.
c. Irrigate the gastric lumen with normal saline.
d. Assess the client for airway patency.

Question 2

A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic in appearance, and the family expresses distress that the client is receiving little dietary protein. How should the nurse respond?

a. A low-protein diet will help the liver rest and will restore liver function.
b. Less protein in the diet will help prevent confusion associated with liver failure.
c. Increasing dietary protein will help the client gain weight and muscle mass.
d. Low dietary protein is needed to prevent fluid from leaking into the abdomen.

josephsuarez · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: 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 treatment. The client should be sedated, balloon pressure should be maintained between 15 and 20 mm Hg, and the lumen can be irrigated with saline or tap water. However, these are not a higher priority than airway patency.

Answer to Question 2

ANS: B
A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the client's dietary protein will cause complications of liver failure and should not be suggested. Increased intravascular protein will help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein.