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 B
Explanation
When a client is receiving gentamicin via IV infusion, it's essential to monitor for potential adverse effects. One of the well-known adverse effects of gentamicin is ototoxicity, which can manifest as hearing loss. Therefore, the nurse should identify the following manifestation as an adverse effect of the treatment:
B) New onset of hearing loss
Hypotension (option A), hyperthermia (option C), and slurred speech (option D) are not typically associated with gentamicin use and would be less likely to be related to the treatment. However, it's essential to assess the client for other side effects and monitor their overall condition while receiving gentamicin to ensure their safety and well-being.
Correct Answer is D
Explanation
The correct answer is D. The parent should apply pressure with gauze if they see bleeding from the circumcision site, as this can indicate a complication such as infection or dislodgement of the plastic ring. The other statements are incorrect because they can interfere with the healing process or cause harm to the infant. Applying antibiotic ointment can cause irritation or allergic reaction, applying a snug diaper can increase pressure and friction on the penis, and wiping away yellow crusts can remove healthy tissue or cause bleeding .
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