CMSRN Medical-Surgical Nursing

Answer - B - Symptoms of severe respiratory distress indicate that the tube has dislodged and is obstructing the airway. Reestablishing an airway is the first priority: Deflate the balloons using a syringe. Following deflation, the doctor should be notified to assess the client’s condition and determine ongoing medical therapy. A code blue would be called only after establishing the airway. Traction on the Sengstaken-Blakemore tube should be increased or decreased only by the attending physician. Iced saline is no longer used for irrigation during active bleeding and this problem is respiratory, not hemorrhagic.