Which finding in a patient who has a Sengstaken-Blakemore tube for esophageal varices is the priority for follow-up?
1. Left lower leg swollen and reddened
2. Absent bowel sounds to lower-left quadrant
3. Decreased level of consciousness
4. 3 cm darkened area on left heel
3
Rationale 1: A swollen and reddened lower leg may indicate a venous thrombus, which is a serious disorder. It is not the highest-priority finding.
Rationale 2: Absent bowel sounds may indicate ileus, which is a serious disorder. It is not the highest-priority finding.
Rationale 3: The patient with a Sengstaken-Blakemore tube is at risk for hypoxia, as the tube has two balloons that are used to tamponade the esophageal bleeding. One balloon is in the stomach and the other is in the esophagus, and if the tube migrates, the airway can be obstructed. Decreased level of consciousness may indicate hypoxia and is the priority for follow-up.
Rationale 4: A darkened area on the heel may indicate a pressure ulcer. This is not the highest-priority finding.
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