The nursing intervention that takes priority for the nursing diagnosis High Risk for Injury related to presence of Sengstaken-Blakemore tube is
A) massaging bony prominences frequently.
B) offering fluids frequently.
C) placing a pair of scissors at the bedside.
D) restraining the client's hands.

Question

Quizplus · Accepted Answer

It is important to ensure that the gastric balloon is inflated to prevent migration of the tube. Scissors should be available at the bedside to remove the tube in an emergency. Complications of balloon tamponade, which include aspiration pneumonitis and esophageal rupture, may occur in 15% or more of clients.

The Nursing Intervention That Takes Priority for the Nursing Diagnosis