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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Ensure that the client gave informed consent: Obtaining informed consent is a critical nursing responsibility prior to any procedure, including an esophagogastroduodenoscopy (EGD). The nurse should verify that the client understands the purpose, risks, and potential outcomes of the procedure. This ensures that the client has voluntarily agreed to undergo the procedure after being fully informed.
B) Administer an oral contrast solution: An esophagogastroduodenoscopy (EGD) does not require the administration of an oral contrast solution. The procedure involves the use of a flexible endoscope to visualize the esophagus, stomach, and duodenum, and is typically performed without contrast agents. Oral contrast is more commonly used in imaging studies such as CT scans or fluoroscopy, not in endoscopy.
C) Inform the client the procedure will take 60 min: The duration of an esophagogastroduodenoscopy typically ranges from 15 to 30 minutes, not 60 minutes. The nurse should inform the client about the usual time frame for the procedure, but stating 60 minutes could be an overestimate. Providing accurate information about the length of the procedure helps manage client expectations.
D) Ensure that the client's bladder is full: The procedure is focused on the upper gastrointestinal tract, so bladder fullness is not necessary for an esophagogastroduodenoscopy. The client should be positioned appropriately, usually in a left lateral position, but there is no need for the bladder to be full. The nurse should ensure that the client follows the pre-procedure guidelines, such as fasting, to reduce the risk of complications.
Correct Answer is A
Explanation
A) Believes the death is punishment for bad behavior: Preschoolers, typically ages 3 to 5, often engage in magical thinking and may believe that death is a result of their own actions or bad behavior. They may see death as a punishment for something they did wrong, as they have difficulty understanding the permanence and inevitability of death. This egocentric thinking is typical for their developmental stage.
B) Recognizes the parent will never wake up: Preschoolers may not yet fully comprehend the permanence of death. They may think the deceased parent will eventually wake up or return. This belief reflects their limited understanding of death, which they may view as reversible or temporary, especially if they haven't encountered death before.
C) Understands that everyone dies eventually: Preschoolers do not generally have the cognitive ability to grasp the concept that everyone dies eventually. This understanding develops later, typically during the concrete operational stage of development (around age 7 or 8), when children begin to understand death as permanent and universal.
D) Expresses curiosity about the funeral service: While some preschoolers may express curiosity about events like a funeral, it is more likely that their curiosity would be centered on simple, tangible aspects of death (such as asking questions about where the person went or what happens to their body) rather than the ceremony itself. At this stage, children may not fully understand the cultural or symbolic meanings of a funeral service.
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