A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first?
a. Sedate the client to prevent tube dislodgement.
b. Maintain balloon pressure at 15 and 20 mm Hg.
c. Irrigate the gastric lumen with normal saline.
d. Assess the client for airway patency.
ANS: D
Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration and occlusion of the airway. The client usually is intubated and mechanically ventilated during this treatment. The client should be sedated, balloon pressure should be maintained between 15 and 20 mm Hg, and the lumen can be irrigated with saline or tap water. However, these are not a higher priority than airway patency.
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