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.

Answer and Explanation

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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Correct Answer is D

Explanation

Answer: D. Prothrombin time

Rationale: Prothrombin time is a measure of how long it takes the blood to clot, which is affected by warfarin, an anticoagulant medication that prevents blood clots from forming or growing larger.

A. Communicate advance directives status via the medical record and shift report. B. Document that the provider discussed do-not-resuscitate status with the client C. Provide the client with written information about advance directives D. Instruct the client that an advance directive is a legal document and must be honored by care providers E. Inform the client that an advance directive discontinues further care. F. Facilitate a power of attorney for health care document.

Correct Answer is ["A","B","C","F"]

Explanation

The nurse is responsible for educating the client and their partner about advance directives and facilitating their decision-making process. Advance directives are legal documents that allow the client to express their preferences for medical care and treatments at the end of life.

They also enable the client to appoint a health care proxy, who is a person who can make health care decisions for the client if they are unable to do so themselves.

The nurse should provide the client with written information about advance directives, document that the provider discussed do-notresuscitate status with the client, and communicate advance directives status via the medical record and shift report.

The nurse should not instruct the client that an advance directive is a legal document and must be honored by care providers, as this may imply coercion or limit the client's right to change their mind.

The nurse should also not inform the client that an advance directive discontinues further care, as this is inaccurate and may discourage the client from completing one.

The nurse should facilitate a power of attorney for health care document only if the client wishes to designate a health care proxy.

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A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

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