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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
The correct answer is D.
Reduced fat in the stools. Pancrelipase is a medication that replaces digestive enzymes produced by the pancreas, which are lacking in most people with cystic fibrosis due to excess mucus production that clogs the pancreatic ducts. By taking pancrelipase, the child can improve their digestion of food and absorb more nutrients, especially fat and fat-soluble vitamins. This will result in reduced fat in the stools, which is a sign of pancreatic insufficiency.
Correct Answer is C
Explanation
The correct answer is C. The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.
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