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. "Two separate samples will be collected to ensure accuracy of the test results." For accuracy, the sweat chloride test is typically done with two separate samples to confirm the diagnosis of cystic fibrosis. The results are compared to ensure consistency.
B. "It will take approximately 3 hours to complete the test." The sweat chloride test typically takes around 30 to 60 minutes, not 3 hours. The process of stimulating sweat production and collecting it is usually brief.
C. "Your child will need to receive sedation to minimize pain during the test." The sweat chloride test is non-invasive and does not require sedation. It involves the application of a sweat-stimulating chemical, and the child may feel mild discomfort but does not require sedation.
D. "Your child should avoid eating and drinking 6 hours prior to the test." There are no specific fasting requirements before a sweat chloride test, although the child may be asked to stay well-hydrated to help produce sweat during the test.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B,C"},"C":{"answers":"B,C"},"D":{"answers":"B"}}
Explanation
Bacterial Meningitis (Most Likely Diagnosis). Headache, nausea, irritability, lethargy, nuchal rigidity → Signs of meningeal irritation Petechiae → Possible meningococcal sepsis. Fever, chills, elevated WBC count (14,000/mm³) → Indicates an infection. Irregular respirations, agitation, capillary refill 4 seconds → Signs of worsening perfusion, possible sepsis
Hodgkin Lymphoma (Possible but Less Likely). Enlarged lymph nodes → Common in lymphoma but does not explain acute symptoms like fever, petechiae, or neurologic signs.
Acute Lymphoblastic Leukemia (ALL) (Possible but Less Likely). Petechiae → Possible due to thrombocytopenia, but child’s platelet count (350,000) is normal.. Enlarged lymph nodes → Can occur in leukemia but is not the primary concern given the acute symptoms.
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