NCLEX-PN

Category - Reduction of Risk

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The nurse is assigned to a client with a Sengstaken-Blakemore tube inserted. Which of the following findings requires the immediate attention of the nurse?

BP 110/70mmHg PR 76 RR 20
BP 90/70mmHg PR 80 RR 16
BP 130/80mmHg PR 105 RR 20
BP 80/60mmHG PR 105 RR 24

Explanation

Answer: D - A Sengstaken-Blakemore tube is used to apply pressure against esophageal varices, controlling bleeding. The nurse should be cautious during a sudden drop of blood pressure and increase in heart rate. These signs indicate esophageal rupture.

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