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robin121 robin121
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6 years ago
Treatment for a client with bleeding esophageal varices has been unsuccessful and the physician decides to insert a Sengstaken-Blakemore tube. The nurse brings which of the following items to the bedside so that it is available at all times?
 
  1. An obturator
  2. A Kelly clamp
  3. An irrigation set
  4. A pair of scissors
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6 years ago
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Rationale: When the client has a Sengstaken-Blakemore tube inserted, a pair of scissors must be kept at the client's bedside at all times. The client must be observed for sudden respiratory dis-tress, which occurs if the gastric balloon ruptures, moving the entire tube upward. If this occurs, all balloon lumens are cut and the tube is removed. An obturator and Kelly clamp would be kept at the bedside of a client with a tracheostomy. An irrigation set may be kept at the bedside but is not the priority item.
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