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

Tape the tube to the child's cheek.

Secure the tubing to the child's abdomen.

Apply water-soluble lubricant to the site.

Attach an extension tube to the site's opening prior to use.

Answer and Explanation

The Correct Answer is B

A) "Tape the tube to the child's cheek."
Taping the tube to the child's cheek is not appropriate for securing a gastrostomy enteral tube. The tube should be securely anchored to the child's abdomen to prevent dislodgment or irritation. Taping to the cheek can lead to unnecessary friction or skin breakdown.

B) "Secure the tubing to the child's abdomen."
The proper method to secure a gastrostomy tube is to anchor the tubing to the child’s abdomen with a specialized securing device or adhesive bandage. This ensures the tube remains in place, minimizing movement and preventing irritation or accidental removal. Proper securing also promotes comfort and safety for the child.

C) "Apply water-soluble lubricant to the site."
Water-soluble lubricant should not be applied directly to the gastrostomy site. This can cause irritation or create a barrier that inhibits proper healing. Instead, the site should be kept clean and dry, with appropriate care to prevent infection or breakdown.

D) "Attach an extension tube to the site's opening prior to use."
While attaching an extension tube may be necessary for feeding or drainage, this action is not related to site care. The focus of site care is to ensure the gastrostomy tube remains securely in place, and the skin around the site is maintained without infection or irritation. Extension tubes are used for feeding or medication administration, not for routine site care.

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Correct Answer is A

Explanation

A) Facial erythema:
Facial erythema is commonly seen in children with pertussis due to the intense coughing fits that are characteristic of the disease. The child may experience bursts of violent coughing, which can lead to a flushed appearance, especially in the face, due to increased pressure during coughing. This manifestation is a common and expected sign in children with pertussis.

B) Peeling of the hands and feet:
Peeling of the hands and feet is not a typical manifestation of pertussis. This is more commonly associated with conditions such as toxic shock syndrome or Kawasaki disease. Pertussis primarily presents with respiratory symptoms such as coughing and a characteristic "whooping" sound, not peeling skin.

C) Fever:
While a mild fever may occur in some children with pertussis, it is not the most prominent symptom. Pertussis is more often characterized by severe coughing fits, which can cause vomiting and a distinctive "whooping" sound, particularly during the paroxysmal stage. Fever is typically mild and not the hallmark of the disease.

D) Beefy, red tongue:
A beefy, red tongue is not a typical finding in pertussis. This symptom is more commonly seen in conditions such as scarlet fever or vitamin B12 deficiency. Pertussis primarily presents with respiratory symptoms like severe coughing and difficulty breathing, and does not typically affect the tongue in this manner.

A. Ensure that the client gave informed consent B. Administer an oral contrast solution. C. Inform the client the procedure will take 60 min. D. Ensure that the client's bladder is full.

Correct Answer is A

Explanation

A) Ensure that the client gave informed consent: Obtaining informed consent is a critical nursing responsibility prior to any procedure, including an esophagogastroduodenoscopy (EGD). The nurse should verify that the client understands the purpose, risks, and potential outcomes of the procedure. This ensures that the client has voluntarily agreed to undergo the procedure after being fully informed.

B) Administer an oral contrast solution: An esophagogastroduodenoscopy (EGD) does not require the administration of an oral contrast solution. The procedure involves the use of a flexible endoscope to visualize the esophagus, stomach, and duodenum, and is typically performed without contrast agents. Oral contrast is more commonly used in imaging studies such as CT scans or fluoroscopy, not in endoscopy.

C) Inform the client the procedure will take 60 min: The duration of an esophagogastroduodenoscopy typically ranges from 15 to 30 minutes, not 60 minutes. The nurse should inform the client about the usual time frame for the procedure, but stating 60 minutes could be an overestimate. Providing accurate information about the length of the procedure helps manage client expectations.

D) Ensure that the client's bladder is full: The procedure is focused on the upper gastrointestinal tract, so bladder fullness is not necessary for an esophagogastroduodenoscopy. The client should be positioned appropriately, usually in a left lateral position, but there is no need for the bladder to be full. The nurse should ensure that the client follows the pre-procedure guidelines, such as fasting, to reduce the risk of complications.

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

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