Question

A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first?

A) Sedate the client to prevent tube dislodgement.
B) Maintain balloon pressure at 15 and 20 mm Hg.
C) Irrigate the gastric lumen with normal saline.
D) Assess the client for airway patency.

Answer 1

The nurse should first assess the client for airway patency when dealing with hemorrhaging from bleeding esophageal varices and an esophagogastric tube.

Step-by-step explanation:

The priority when caring for a client who is experiencing hemorrhaging from bleeding esophageal varices is to ensure airway patency. This is because an obstructed airway can rapidly lead to respiratory arrest and is immediately life-threatening. Therefore, the nurse should first assess the client for airway patency before proceeding with other interventions such as sedating the client, maintaining balloon pressure, or irrigating the gastric lumen.