NCLEX RN Exam Questions - Nurselytic

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Question 1 of 5

A 53-year-old patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care?

Correct Answer: B

Rationale: The correct nursing action for a patient with balloon tamponade for bleeding esophageal varices is to monitor the patient for shortness of breath. The most common complication of balloon tamponade is aspiration pneumonia. Additionally, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Instructing the patient to cough every hour is incorrect as coughing increases the pressure on the varices and raises the risk of bleeding. Verifying the position of the balloon every 4 hours is unnecessary as it is typically done after insertion. Deflating the gastric balloon if the patient reports nausea is incorrect because deflating it may cause the esophageal balloon to occlude the airway, leading to complications.
Therefore, monitoring for signs of respiratory distress is crucial in this situation.

Question 2 of 5

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Question 3 of 5

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Question 5 of 5

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