A nurse is providing site care for a child who a gastrostomy enteral tube. Which of the following actions should the nurse take?
Tape the tube to the child's cheek.
Secure the tubing to the child's abdomen.
Apply water-soluble lubricant to the site.
Attach an extension tube to the site's opening prior to use.
The Correct Answer is B
A) "Tape the tube to the child's cheek."
Taping the tube to the child's cheek is not appropriate for securing a gastrostomy enteral tube. The tube should be securely anchored to the child's abdomen to prevent dislodgment or irritation. Taping to the cheek can lead to unnecessary friction or skin breakdown.
B) "Secure the tubing to the child's abdomen."
The proper method to secure a gastrostomy tube is to anchor the tubing to the child’s abdomen with a specialized securing device or adhesive bandage. This ensures the tube remains in place, minimizing movement and preventing irritation or accidental removal. Proper securing also promotes comfort and safety for the child.
C) "Apply water-soluble lubricant to the site."
Water-soluble lubricant should not be applied directly to the gastrostomy site. This can cause irritation or create a barrier that inhibits proper healing. Instead, the site should be kept clean and dry, with appropriate care to prevent infection or breakdown.
D) "Attach an extension tube to the site's opening prior to use."
While attaching an extension tube may be necessary for feeding or drainage, this action is not related to site care. The focus of site care is to ensure the gastrostomy tube remains securely in place, and the skin around the site is maintained without infection or irritation. Extension tubes are used for feeding or medication administration, not for routine site care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Position the client’s head toward Mecca: In Islam, it is customary to position the deceased's body with the head facing toward Mecca, the holy city of Islam. This is an important religious practice and should be followed during postmortem care to respect the deceased's cultural and religious beliefs.
B) Allow a family member of the client to stay with the client’s body until burial: It is customary in many Islamic traditions for a family member to stay with the body, providing comfort and ensuring the body is treated with respect. However, the nurse should ensure this is done within the hospital's policies and in a safe, culturally sensitive manner. This practice should be respected, but it is not the immediate priority for the nurse during postmortem care.
C) Allow a family member to stay with the client’s body for 8hr: While some Islamic traditions may involve family members staying with the body, the nurse should adhere to the specific wishes of the family and the institution's policies. The 8-hour duration is not a specific religious requirement, and the focus should be on providing respectful, appropriate care and ensuring the family’s wishes are honored within the hospital's guidelines.
D) Position the client’s head northward: In Islamic traditions, the body is positioned with the head facing toward Mecca, not northward. Positioning the head in a direction other than toward Mecca would not align with the cultural practices of Islam regarding postmortem care. Therefore, this action would not be appropriate.
Correct Answer is ["A","B","D","F","G","I"]
Explanation
Yellowing of the eyes (Jaundice) → Isoniazid and Rifampin can cause hepatotoxicity, leading to jaundice.
Blurred vision → Ethambutol can cause optic neuritis, leading to blurred vision and color blindness.
Dry eyes (Incorrect) → Not a common side effect of TB medications.
Gastrointestinal:
Abdominal pain → Isoniazid, Rifampin, and Pyrazinamide are hepatotoxic and can cause liver inflammation and gastric irritation.
Weight gain (Incorrect) → TB medications are more likely to cause weight loss rather than gain.
Hematologic:
Increased bruising & bleeding tendencies → Rifampin can cause thrombocytopenia, increasing the risk of bruising and bleeding.
Insomnia (Incorrect) → Not a serious adverse effect of TB medications.
Genitourinary:
Darkening of the urine → Rifampin causes orange-red discoloration of urine, sweat, and tears, which is a benign but expected effect.
Urinary frequency (Incorrect) → Not a known adverse effect of TB medications.
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