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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["20"]
Explanation
To convert weight from pounds to kilograms, divide by 2.2.
Weightinkg = Weightinlbs ÷2.2
= 44÷ 2.2
= 20 kg
Correct Answer is A
Explanation
a) A slowing of the client's heart rate: The Valsalva maneuver (straining during defecation) can cause a transient increase in intra-abdominal pressure, which triggers vagal stimulation, leading to a slowing of the heart rate (bradycardia).
b) A decrease in the client's blood pressure: The Valsalva maneuver may initially cause an increase in blood pressure, followed by a drop after the maneuver is released. The immediate effect is a slowing of the heart rate, not a decrease in blood pressure.
c) An increase in the client's respiratory rate: The Valsalva maneuver typically causes a temporary decrease in respiratory rate due to the strain on the body.
d) A decrease in the client's respiratory rate: The Valsalva maneuver does not typically result in a significant decrease in respiratory rate. Instead, it is more likely to cause a brief alteration in heart rate and blood pressure.
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