The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to:
A. Check that the hemostat is on the bedside
B. Monitor IV fluids for the shift
C. Regularly assess respiratory status
D. Check that the balloon is deflated on a regular basis
Answer: C
Explanation: The respiratory system can become occluded if the balloon slips and moves up the esophagus, putting pressure on the trachea. This would result in respiratory distress and should be assessed frequently. Scissors should be kept at the bedside to cut the tube if distress occurs. This is a safety intervention.
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