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. "Have the child bend forward at the waist and check for asymmetry of the scapula." This maneuver is known as the Adam's forward bend test and is used to screen for scoliosis, which commonly appears during adolescence.
B. "Auscultate the abdomen for at least 1 min if bowel sounds are absent." If bowel sounds are absent, the nurse should listen for at least 5 minutes in each quadrant before concluding they are truly absent.
C. "Use the FACES scale to assess pain." The FACES scale is typically used for younger children (3-7 years old). Adolescents can usually use a numeric rating scale (0-10) for pain assessment.
D. "Observe abdominal movement to determine the respiratory rate." Abdominal breathing is characteristic of infants and younger children. In adolescents, the nurse should observe chest movement to assess respiratory rate.
Correct Answer is B
Explanation
A. "Offer your child foods that are low in calories." Children with cystic fibrosis (CF) require a high-calorie diet because their bodies have difficulty absorbing nutrients due to pancreatic insufficiency.
B. "Offer your child foods that are high in fat." A high-fat diet (35%-40% of total calories from fat) is recommended because fat malabsorption is common in CF, and they need additional fat to meet their energy needs.
C. "Offer your child foods that are high in vitamin C." While vitamin C is important, fat-soluble vitamins (A, D, E, and K) are the primary concern since CF patients struggle to absorb them.
D. "Offer your child foods that are low in protein." Children with CF require adequate protein intake to support growth and maintain muscle mass, so protein restriction is not recommended.
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