Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the client appears to be having difficulty breathing. The nurse’s first action should be to:
1. Remove the tube.
2. Deflate the esophageal portion of the tube.
3. Determine whether the tube is obstructing the airway.
4. Increase the oxygen flow rate.
If the gastric balloon should rupture or deflate, the esophageal balloon can move and partially or totally obstruct the airway, causing respiratory distress. The client must be observed closely. No direct action should be taken until the condition is accurately diagnosed.
CN: Reduction of risk potential; CL: Synthesize
小编寄语：Life is nothing more than facing two worlds, the outside world and your own inner world.人生，无非是面对两大世界，身外的大千世界和自己的内心世界。