A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

A.Restraints should never be applied directly on the skin or under clothing, as this can cause irritation, pressure injuries, and make it difficult for the nurse to assess skin integrity. Restraints should be placed over the client's clothing to reduce friction and protect the skin.

B.Positioning the client in a sitting or semi-Fowler's position is preferred as it promotes comfort, minimizes the risk of aspiration, and allows the nurse to monitor the client's airway, breathing, and circulation more effectively. Lying flat can increase discomfort and respiratory difficulty, especially if the client is aggressive or agitated.

C.Restraints should never be tied to movable parts, like bed rails, as this could result in injury if the bed rail is moved up or down. Restraints should be tied to a non-movable part of the bed frame to ensure stability and prevent accidental tightening or loosening that could harm the client.

D.A belt restraint should be placed across the client’s waist or hips, not the chest, as a chest restraint can impede respiratory function, especially in an aggressive client who may be physically exerting themselves. The restraint should secure the client’s lower body to prevent them from standing or moving excessively, while still allowing safe breathing and circulation.

Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.

Taping the tube to the child's cheek is not typically done as it can cause discomfort and skin irritation. The tube should be secured with a stabilization device or a specialized dressing designed for gastrostomy tube care.

Applying a skin barrier protectant around the gastrostomy site is a good practice. It helps protect the skin from irritation, breakdown, and leakage of gastric contents, which can cause skin excoriation. This helps maintain the integrity of the skin around the site.

Applying water-soluble lubricant to the site is not necessary for routine site care. Lubrication is typically used when inserting or removing the tube, but it is not part of routine site care.