Medical Surgical Esophageal varices #3

Question

A client with esophageal varices begins to profusely bleed from the mouth. What is the nurse’s priority action?

Answers

  1. Contact the health care provider immediately
    • Rationale:

      This answer is not correct because although the health care provider does need to be contacted as soon as possible, it should not be done before assuring the client’s airway is as clear as possible and decreasing the risk of aspiration.

  2. Raise the head of the bed to high-Fowler’s
    • Rationale:

      This answer is correct because protecting the client’s airway and attempting to prevent aspiration from profuse bleeding is the nurse’s priority intervention. Then the health care provider contacted and following the provider’s orders, including scheduling an emergency balloon tamponade, increasing fluids, and administering an antibiotic. Airway and breathing is the priority before circulation.

  3. Schedule an emergency balloon tamponade
    • Rationale:

      This answer is not correct because scheduling an emergency balloon tamponade may be an expected intervention, it is not the first action of the nurse. Protecting the client’s airway and attempting to prevent aspiration from profuse bleeding is the nurse’s priority intervention. Then the health care provider contacted and following the provider’s orders, including scheduling an emergency balloon tamponade, increasing fluids, and administering an antibiotic. Airway and breathing is the priority before circulation.

  4. Increase fluids and call for an antibiotic
    • Rationale:

      This answer is not correct because increasing fluids and administering an antibiotic may be an expected intervention after notification of the health care provider, it is not the first action of the nurse. Protecting the client’s airway and attempting to prevent aspiration from profuse bleeding is the nurse’s priority intervention. Airway and breathing is the priority before circulation.

Overview

The priority action for a spontaneous rupture of an esophageal varices is to raise the head of the bed to prevent aspiration.

Explanation

Learning Outcomes

Esophageal varices are swollen, bulging veins located in the lower esophagus. This occurs as the result of increased blood pressure in the portal vein. The hypertension in the portal vein is associated with liver damage related to cirrhosis of the liver. The varices can be easily damaged, then rupture, and bleed. The nurse’s priority action for a spontaneous rupture of an esophageal varices is to raise the head of the bed to prevent aspiration. Then the healthcare provider should be notified and fluids administered and other hypovolemia prevention as prescribed. The nurse should delegate scheduling an emergency balloon tamponade or an endoscopic band ligation procedure as prescribed by the health care provider.

Test Taking Tip

Always remember following the priorities of caring for a client with the ABCs of nursing care: Airway, breathing, circulation.

Video Rationale