A nurse is preparing to care for a female client with esophageal varices who just had a Sengstaken-Blakemore tube inserted. The nurse gathers supplies, knowing that which of the following items must be kept at the bedside at all times?
A. An obturator
B. Kelly clamp
C. An irrigation set
D. A pair of scissors
Correct Answer: D. A pair of scissors
When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client’s bedside at all times. The client needs to be observed for sudden respiratory distress, which occurs if the gastric balloon ruptures and the entire tube moves upward. If this occurs, the nurse immediately cuts all balloon lumens and removes the tube. Sengstaken-Blakemore tube placement is indicated for unstable patients with uncontrolled hemorrhage. Sengstaken-Blakemore tube placements can temporarily control the hemorrhage.
Option A: An obturator is kept at the bedside of a client with a tracheostomy. This is a piece of rigid plastic, silicone, or metal that fits inside the outer cannula when a tracheostomy tube is being inserted. It helps guide the tracheostomy tube into place, causing less damage to the tissues.
Option B: A Kelly clamp is kept at the bedside of a client with a tracheostomy. Clinicians must be prepared in case of emergency as the medical condition of a patient with tracheostomy and/or mechanical ventilation may change quickly. Emergency equipment is necessary at the bedside as well as during the transportation.
Option C: An irrigation set may be kept at the bedside, but it is not the priority item. Airway protection remains the foremost focus. If the patient is requiring a Sengstaken-Blakemore tube placement, they have likely already been intubated for airway protection, but if not, endotracheal intubation should be performed prior to placement. Following intubation, the patient should be placed in the supine position with the head of the bed elevated to 45 degrees.
No comments:
Post a Comment