A patient with esophageal varices is being treated with an esophageal tamponade (Sengstaken-Blakemore) tube. What should be the nurse's priority when caring for this patient?
1. Ensuring that the gastric balloon remains inflated
2. Keeping a pair of scissors at the bedside at all times
3. Keeping the patient sedated and quiet
4. Maintaining the esophageal balloon pressure between 15 and 20 mm Hg
2
Rationale 1: This is important but airway always takes priority.
Rationale 2: Accidental migration of the tube can result in airway obstruction. This requires immediate intervention by cutting all the lumens of the tube to rapidly deflate them and removing the tube. Maintenance of the airway is the priority.
Rationale 3: Although this is important to keep the patient from pulling out the tube, airway takes priority.
Rationale 4: Although it is important to maintain this pressure against the varices to prevent bleeding, maintaining the airway is the priority.
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