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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) "I will get you information about some head-covering options."
This response acknowledges the client's concern about hair loss and provides a supportive and proactive solution. Many chemotherapy clients experience hair loss, and offering resources for head coverings shows empathy while helping them cope with the anticipated changes in appearance. It demonstrates the nurse's willingness to assist the client with emotional and physical challenges related to treatment.
B) "Let’s discuss this when we have more time."
Delaying the discussion about hair loss is not ideal. It dismisses the client’s current concern and may make the client feel like their feelings are not a priority. Hair loss can be a significant emotional challenge, and the nurse should address it in a timely and compassionate manner rather than postponing the conversation.
C) "I can’t imagine how difficult it would be to lose my hair."
While this response is empathetic, it focuses on the nurse's feelings instead of addressing the client's concern. It is important to maintain a client-centered approach and focus on the client's needs. The nurse should offer concrete support or information, such as head-covering options, rather than expressing personal emotions that may not be helpful to the client.
D) "I wouldn’t worry about this right now. Let's focus on your chemotherapy."
This response dismisses the client's concern about hair loss, which can be a significant issue for many clients starting chemotherapy. Minimizing the concern or suggesting it is not worth discussing at this time may make the client feel unheard or undervalued. It’s important to acknowledge the client’s worries and provide support for them to manage the emotional impacts of chemotherapy.
Correct Answer is D
Explanation
A) Beefy, red tongue: The beefy, red tongue is typically associated with scarlet fever, a bacterial infection caused by group A Streptococcus. This condition can lead to a red, "strawberry" tongue, often accompanied by a rash. While measles can involve a variety of symptoms, including a red rash, conjunctivitis, and cough, the beefy red tongue is not characteristic of measles. In measles, the more notable symptoms are a high fever, cough, runny nose, and the development of Koplik spots inside the mouth.
B) Paroxysmal cough: Paroxysmal cough, which is a sudden, severe, and uncontrollable cough often followed by a "whooping" sound, is more characteristic of pertussis (whooping cough). While a cough is indeed present with measles, it is generally not paroxysmal. In measles, the cough is more persistent and associated with other typical symptoms such as fever and a characteristic rash. The coughing in measles may also be dry and harsh but does not tend to occur in violent, paroxysmal episodes like those seen in pertussis.
C) Peeling of the hands and feet: Peeling of the skin, particularly of the hands and feet, is more commonly observed in conditions such as scarlet fever, Kawasaki disease, or after a viral infection like hand-foot-and-mouth disease. It is not a classic finding of measles. In measles, the skin rash usually starts as maculopapular spots on the face and spreads down the body. While some skin sloughing can occur after the rash resolves, especially in severe cases, it is not the characteristic sign of measles, and it is not typically seen on the hands and feet.
D) Fever: Fever is one of the earliest and most prominent symptoms of measles. It typically appears about 2-4 days before the characteristic measles rash. The fever in measles can be quite high, often exceeding 104°F (40°C), and is associated with other symptoms such as cough, conjunctivitis, and photophobia. The fever usually persists for several days, and it is one of the critical signs that lead to the diagnosis of measles, particularly when combined with the characteristic rash and other respiratory symptoms.
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