6-year-old child.
Vomited 3 times in the past 24 hr. Irritable behavior for the past 24 hr. The respiratory infection started 3 days ago.
Brudzinski's and Kernig's signs are positive.
Vital Signs.
Respiratory rate 28/min.
Pulse rate 120/min.
BP 108/64 mm Hg. Pain level of 6 on a scale from 0 to 10. Medication Administration Record.
Vancomycin 300 mg IV q 6 hr following blood cultures.
Acetaminophen 240 mg PO q 6 hr PRN fever.
A nurse is planning care for a child during admission to the facility.
Which of the following actions should the nurse take first?
Obtain a prescription for pain medication.
Initiate seizure precautions.
Collect blood cultures.
Transport the child to obtain a CT scan.
The Correct Answer is B
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Correct Answer is D
Explanation
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 lubricant to the site is not necessary or recommended. The gastrostomy tube should be kept clean and dry. If any secretions or debris are present, they should be gently cleaned with mild soap and water, followed by thorough rinsing and drying.
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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