Practice Quiz

CMSRN Medical-Surgical Nursing

Category - Gastrointestinal

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Mr. Tuxen’s esophageal varices ruptured and he was having hematemesis. A Sengstaken-Blakemore tube is inserted in an effort to stop the bleeding. After the Sengstaken-Blakemore tube is inserted, the client has difficulty in breathing. Based on this information, the first action the nurse should take is to:
  1. Deflate the esophageal balloon
  2. Encourage him to take deep breaths
  3. Monitor his vital signs
  4. Notify the physician
Explanation
Answer - A - If the client experiences difficulty breathing after insertion and inflation of the balloon, the catheter must have been inserted into the airway and obstruction has occurred after inflation of the balloon. The first nursing action is to deflate the balloon to release the obstruction and enable the client to breathe.
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