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) Staff members used a class A fire extinguisher during an electrical fire.
This response indicates that the safety plan is effective because it shows that the staff used the correct type of fire extinguisher for the fire they encountered. Class A fire extinguishers are designed for ordinary combustibles (e.g., wood, paper, cloth), but using a fire extinguisher that is correctly suited to the fire type demonstrates that the staff are trained and prepared to respond appropriately in an emergency. For electrical fires, however, a Class C fire extinguisher should be used. This suggests a review of fire safety plan training might be necessary to align fire extinguisher types with fire classes.
B) Staff members review the locations of fire extinguishers every 2 to 3 years.
Reviewing the locations of fire extinguishers every 2 to 3 years is not an adequate frequency. Fire safety protocols should be reviewed more frequently to ensure that staff are consistently aware of fire extinguisher locations. Routine and more frequent checks (e.g., annually) are required to ensure proper preparedness in an emergency.
C) An evacuation was ordered during a fire when fire extinguishers were not effective.
While evacuations are necessary in certain situations, an evacuation being ordered because fire extinguishers were ineffective could indicate that the safety plan was not properly executed or that there was an issue with fire extinguisher maintenance or staff training. The effectiveness of fire safety plans should reduce the need for evacuations due to inadequate response efforts.
D) Fire alarms in the facility have the same sound as other alarms.
Fire alarms should have a distinct sound that differentiates them from other types of alarms (e.g., medical or security alarms). If fire alarms have the same sound as other alarms, it could create confusion in an emergency, undermining the effectiveness of the safety plan. The alarm system should be unique and easily identifiable.
Correct Answer is D
Explanation
A) "Carry your newborn back to the nursery in your arm when you need to rest.": This statement is not recommended. Carrying the newborn around, especially when the mother is feeling fatigued or unwell, can increase the risk of accidental drops or falls. Newborns should be placed in a bassinet or crib, and if the mother needs to rest, she should use assistance to ensure the baby is safely secured in their sleeping area.
B) "Request that the nurses show their nursing license prior to removing your newborn from the room.": While it’s important to ensure that the staff is authorized to care for the newborn, it may not be practical or necessary to request to see a nursing license every time someone comes to take the baby. Instead, the hospital usually has strict protocols in place for identifying staff, and it is better to rely on the facility's established security measures to verify authorized personnel.
C) "Leave your newborn in the bassinet in your room while you use the bathroom.": This statement is not ideal because, while it may seem safer to leave the baby in the bassinet, the nurse should encourage the mother to keep the baby nearby or alert a nurse to assist if needed. It is safer to have the baby in a secure place or ask for help to avoid the risk of falls or accidents while the mother is not attending to the baby.
D) "Alert the staff if any of your newborn's identification bands are missing.": This is the correct and most important instruction. Newborns should always be closely monitored to prevent abductions or mix-ups, and the identification bands are critical for verifying the baby's identity. If any identification bands are missing, it is essential to notify the staff immediately to ensure the newborn’s safety and prevent any potential security risks.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.