Question:

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.

Answer:3

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

翻译

问题：

在插入双气囊三腔管30分钟后，护士观察到病人似乎呼吸困难。护士的第一个行动应该是：

1.移除管。

2.将管的食道部分放气。

3.确定导管是否阻塞气道。

4.增加氧气流速。

答案：3

如果胃球囊破裂或放气，食道球囊会移动并部分或完全阻塞气道，导致呼吸窘迫。必须密切观察客户。在准确诊断病情之前，不应采取直接措施。

CN：降低潜在风险；CL：综合

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。