Elevate NCLEX Preparation # 06

Elevate NCLEX Preparation # 06

December 05, 2024

Thursday

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The nurse is caring for a client with a balloon tamponade tube in place due to bleeding esophageal varices. The client suddenly develops respiratory distress, and the nurse finds that the tube has been partially pulled out. Which intervention should be the nurse's priority?

Contact the health care provider

Increase gastric suction level

Cut the tube with scissors

Place the client in high Fowler position

A balloon tamponade tube (eg, Sengstaken-Blakemore, Minnesota) is used to temporarily control bleeding from esophageal varices. It contains 2 balloons and 3 lumens. The gastric lumen drains stomach contents, the esophageal balloon compresses bleeding varices above the esophageal sphincter, and the gastric balloon compresses from below. A weight is attached to the external end of the tube to provide tension and hold the gastric balloon securely in place below the esophageal sphincter. Airway obstruction can occur if the balloon tamponade tube becomes displaced and a balloon migrates into the oropharynx. Scissors are kept at the bedside as a precaution; in the event of airway obstruction, the nurse can emergently cut the tube for rapid balloon deflation and tube removal (Option 2).

(Option 1) If airway obstruction occurs, the nurse should first clear the airway and then ensure that the client is stable before contacting the health care provider.

(Option 3) Low intermittent suction to the gastric lumen of a balloon tamponade tube is used to drain stomach contents. Increasing the suction would not be indicated if the tube has become displaced.

(Option 4) If the balloon tamponade tube is displaced and obstructing the airway, changing the client's position will not help until the client's airway is cleared by removing the tube.

Educational objective: A balloon tamponade tube is used to compress bleeding esophageal varices. Tube displacement may result in airway obstruction. The nurse should keep scissors at the bedside so that the tube can be emergently cut and removed if respiratory distress develops due to tube displacement.

A balloon tamponade tube (eg, Sengstaken-Blakemore, Minnesota) is used to temporarily control bleeding from esophageal varices. It contains 2 balloons and 3 lumens. The gastric lumen drains stomach contents, the esophageal balloon compresses bleeding varices above the esophageal sphincter, and the gastric balloon compresses from below. A weight is attached to the external end of the tube to provide tension and hold the gastric balloon securely in place below the esophageal sphincter. Airway obstruction can occur if the balloon tamponade tube becomes displaced and a balloon migrates into the oropharynx. Scissors are kept at the bedside as a precaution; in the event of airway obstruction, the nurse can emergently cut the tube for rapid balloon deflation and tube removal (Option 2).

(Option 1) If airway obstruction occurs, the nurse should first clear the airway and then ensure that the client is stable before contacting the health care provider.

(Option 3) Low intermittent suction to the gastric lumen of a balloon tamponade tube is used to drain stomach contents. Increasing the suction would not be indicated if the tube has become displaced.

(Option 4) If the balloon tamponade tube is displaced and obstructing the airway, changing the client's position will not help until the client's airway is cleared by removing the tube.

Educational objective: A balloon tamponade tube is used to compress bleeding esophageal varices. Tube displacement may result in airway obstruction. The nurse should keep scissors at the bedside so that the tube can be emergently cut and removed if respiratory distress develops due to tube displacement.

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