A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?
Tape the tube to the child's cheek.
Apply water-soluble lubricant to the site.
Attach an extension tube to the site's opening prior to use.
Secure the tubing to the child's abdomen.
The Correct Answer is D
A. Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.
B. Applying water-soluble lubricant to the gastrostomy site routinely is not recommended because it can trap moisture, leading to maceration or infection.
C. 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.
D. Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
This action requires intervention by the nurse. Antiembolic stockings should be smooth and free of creases to ensure even pressure distribution along the legs. Creases, especially if on the front of the legs, can lead to areas of increased pressure, which might compromise circulation and increase the risk of skin breakdown or clot formation.
Choice B rationale:
Applying the stockings before the client gets out of bed is correct. Antiembolic stockings should be applied before the client gets out of bed to prevent blood from pooling in the legs, which can help reduce the risk of deep vein thrombosis (DVT).
Choice C rationale:
Asking the client to point their toes before applying the stockings is a correct action. This helps in the proper fitting of the stockings and ensures they are applied smoothly without causing discomfort.
Choice D rationale:
Turning the stockings inside out (at least down to the heel) before applying them is a common technique to make it easier to position the stocking on the foot and leg properly. This method helps avoid excessive stretching of the stocking and ensures a better fit.
Correct Answer is A
Explanation
Choice A reason:
"Use a cane when walking to maintain your balance" is the correct statement Multiple sclerosis (MS) is a chronic autoimmune condition that affects the central nervous system, leading to various neurological symptoms. Mobility and balance issues are common among individuals with MS, and using a cane can be helpful in providing stability and support while walking. It can also reduce the risk of falls and improve the client's overall safety and confidence when ambulating.
Choice B reason:
"Plan to take a hot bath once a week to reduce stress” is not appropriate statement. Heat sensitivity is a common symptom in individuals with MS, and exposure to heat, such as hot baths or saunas, can exacerbate MS symptoms. It is generally advisable for individuals with MS to avoid excessive heat exposure as it can worsen fatigue and other neurological symptoms.
Choice C reason:
"Engage in a rigorous exercise program to maintain muscle tone" is not appropriate. While exercise is beneficial for individuals with MS, particularly in maintaining muscle strength and flexibility, it is essential to avoid a rigorous or overly strenuous exercise program. High-intensity exercise may lead to increased fatigue and exacerbation of MS symptoms. A personalized exercise plan that considers the individual's specific abilities and limitations is recommended.
Choice D reason
"Place a scatter rug in your bathroom to prevent falling" is not appropriate statement. Placing a scatter rug in the bathroom is not advisable, especially for individuals with mobility and balance issues like those with MS. Scatter rugs can create tripping hazards and increase the risk of falls. It is essential to keep the bathroom floor clear and use non-slip mats to improve safety.

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