Which of the following is an appropriate nursing action for skin irritation around the Gastrostomy tube site?
Providing a skin barrier for any drainage at the site
Turn the client to the side
Apply adhesive bandage directly to the skin
Keep the head of bed 25 degrees
The Correct Answer is A
a) Providing a skin barrier for any drainage at the site: Protecting the skin from moisture or drainage prevents further irritation or breakdown. Skin barriers help maintain skin integrity.
b) Turn the client to the side: Positioning may help with aspiration prevention but does not address skin irritation around the G-tube site.
c) Apply adhesive bandage directly to the skin: Adhesive bandages can further irritate or damage already sensitive skin and are not recommended for irritated or moist areas.
d) Keep the head of bed 25 degrees: While semi-Fowler’s positioning (30–45°) is good for preventing aspiration, this is unrelated to treating skin irritation directly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a) School-age child: While a school-age child is at risk for dehydration, their fluid and electrolyte imbalance risk is less than that of an infant due to greater reserve and more effective compensatory mechanisms.
b) Adolescent: Similar to the school-age child, an adolescent is at lower risk for severe fluid and electrolyte imbalances due to a better-developed system to handle fluid loss.
c) Young adult: While diarrhea can lead to dehydration in young adults, they are generally more capable of compensating for mild to moderate fluid losses compared to infants.
d) Infant: Infants are at the highest risk for severe fluid and electrolyte imbalance due to their smaller body size, higher fluid turnover, and less efficient compensatory mechanisms. Dehydration can develop quickly in infants.
Correct Answer is D
Explanation
a) Mixing the specimen with developer prior to sending to the lab: The nurse is not responsible for mixing stool specimens with developer unless specified by a particular test protocol. The nurse typically sends the specimen as is.
b) Asking the patient to call the nursing station when the stool specimen has been collected: While the nurse may inform the patient of the need to call once the specimen is collected, the nurse is ultimately responsible for managing the collection process, not just the patient’s communication.
c) Leaving this responsibility for the oncoming nurse: The nurse is responsible for collecting and handling specimens according to the facility's procedures. The oncoming nurse would take over once the current nurse's shift ends, but the specimen collection should be completed during the current shift.
d) Obtaining the specimen according to facility procedure: The nurse is responsible for obtaining stool specimens following the specific procedures set by the facility to ensure proper collection and handling for accurate results.
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