A nurse is caring for a preschooler who has a gastrostomy tube. Which of the following actions should the nurse take?
Use barrier ointments around the site.
Cleanse the tube site with hydrogen peroxide.
Maintain tension between the tubing and the site.
Place a transparent occlusive dressing over the site.
The Correct Answer is A
A. "Use barrier ointments around the site." Barrier ointments (such as zinc oxide or petroleum-based products) help prevent skin irritation and breakdown caused by leakage of gastric contents.
B. "Cleanse the tube site with hydrogen peroxide." Hydrogen peroxide can be too harsh and may delay healing or cause irritation to the skin. Mild soap and water or saline are recommended for cleaning.
C. "Maintain tension between the tubing and the site." The tube should be secured but not under tension, as excessive pulling can cause discomfort, skin breakdown, or accidental dislodgement.
D. "Place a transparent occlusive dressing over the site." A gauze dressing may be used if there is drainage, but a transparent occlusive dressing can trap moisture, increasing the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Obtain a blood culture. The first action is to obtain a blood culture to identify the causative organism before starting antibiotic therapy. This ensures that the appropriate antibiotic is selected.
B. Request a referral for physical therapy. Physical therapy may be needed later, but it is not the priority during admission.
C. Administer IV antibiotics. Antibiotics should be given after obtaining a blood culture to avoid altering the test results.
D. Record intake and output. While monitoring fluid balance is important, it is not the priority action during admission.
Correct Answer is D
Explanation
A. Increased urine output. Infants with congestive heart failure (CHF) often have decreased urine output due to reduced kidney perfusion caused by poor cardiac function.
B. Bradycardia. CHF is more likely to cause tachycardia as the heart compensates for poor circulation.
C. Increased blood pressure. CHF in infants typically leads to hypotension or normal blood pressure rather than an increase.
D. Tachypnea. Increased respiratory rate (tachypnea) is a common sign of CHF in infants because of fluid overload and pulmonary congestion, which make breathing difficult.
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