The nursing intervention that takes priority for the nursing diagnosis High Risk for Injury related to presence of Sengstaken-Blakemore tube is
a. massaging bony prominences frequently.
b. offering fluids frequently.
c. placing a pair of scissors at the bedside.
d. restraining the client's hands.
C
It is important to ensure that the gastric balloon is inflated to prevent migration of the tube. Scis-sors should be available at the bedside to remove the tube in an emergency. Complications of balloon tamponade, which include aspiration pneumonitis and esophageal rupture, may occur in 15% or more of clients.
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