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 ["C","E"]

Explanation

A. Encourage prolonged dangling before ambulation.
Prolonged dangling is not necessary for this client, who is already ambulating independently. Extended dangling may increase the risk of orthostatic hypotension without providing significant benefits.

B. Administer an enema.
An enema is not the first-line intervention for postoperative constipation. The client has had a bowel movement, albeit small and painful, so increasing fluids and noninvasive measures like a sitz bath should be attempted first.

C. Encourage oral fluid intake.
Adequate hydration helps soften stool and prevent constipation, a common postoperative concern. The client’s fluid intake should be increased to support bowel function and improve urinary output.

D. Irrigate indwelling catheter with 500 mL of fluid.
The client has pink urine but is maintaining an adequate output of 100 mL/hr. Routine catheter irrigation is unnecessary unless there is evidence of obstruction, such as decreased urine flow or clot formation.

E. Assist the client with a sitz bath.
A sitz bath can provide comfort by promoting relaxation of perineal muscles, reducing pain during bowel movements, and improving circulation to the surgical site, which may aid healing.

A. "My baby will receive the rotavirus immunization orally." B. should expect my baby to have a high fever for 24 hours after an immunization." C. "I should not feed my baby anything for hours prior to an immunization." D. "My baby will receive three doses of the meningococcal immunization before kindergarten."

Correct Answer is A

Explanation

A) "My baby will receive the rotavirus immunization orally.":
This statement is correct. The rotavirus vaccine is given orally in two or three doses depending on the specific vaccine used (Rotarix or RotaTeq). The vaccine is administered in the mouth and helps protect against rotavirus infections, which can cause severe diarrhea in infants and young children.

B) "I should expect my baby to have a high fever for 24 hours after an immunization.":
This statement is incorrect. While it is common for infants to experience mild side effects after immunizations, such as a low-grade fever or irritability, a high fever is not typically expected. If the baby develops a high fever (above 100.4°F), the guardian should seek advice from the healthcare provider, as it could indicate a reaction or infection.

C) "I should not feed my baby anything for hours prior to an immunization.":
This statement is incorrect. There is no need to withhold feeding before an immunization, and the baby should be fed as usual. In fact, feeding the infant before the appointment may help comfort them and reduce stress during the visit.

D) "My baby will receive three doses of the meningococcal immunization before kindergarten.":
This statement is incorrect. The meningococcal vaccine is typically administered starting at age 11, with a second dose given at age 16. For infants and young children, the vaccine is not part of the routine immunization schedule. Meningococcal vaccination before kindergarten is not recommended for infants at 2 months of age.

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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?

Nursing Test Bank

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Correct Answer is ["C","E"]

Explanation

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Correct Answer is A

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