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

Tape the tube to the child's cheek.

Apply water-soluble lubricant to the site.

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

Secure the tubing to the child's abdomen.

Answer and Explanation

The Correct Answer is D

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 water-soluble lubricant to the gastrostomy site routinely is not recommended because it can trap moisture, leading to maceration or infection.

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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Correct Answer is B

Explanation

The correct answer is B. The taking-in phase of maternal adjustment is characterized by the passive and dependent behavior of the mother, who focuses on her own needs and relies on others for assistance. The mother is eager to review the birth experience and share her feelings with others, which helps her process and integrate what happened. The other options are incorrect because they describe manifestations of other phases of maternal adjustment: tolerating physical discomforts and performing self-care independently are typical of the taking-hold phase while beginning reconnecting with their partner is typical of the letting-go phase.

A. Ensure the client swallows each dose of medication. B. Limit the personal toiletries in the client's room to cologne. C. Keep the client's door shut when they are in the room. D. Observe the client's behavior every 2 hr.

Correct Answer is A

Explanation

The correct answer is A.

Ensure the client swallows each dose of medication. A client who recently attempted suicide is at high risk of another suicide attempt and needs closemonitoring and supervision. The nurse should ensure that the client swallows each dose of medication to prevent hoarding or overdosing on pills. The nurse should also remove any potential means of self-harm from the client's room, such as sharp objects, belts, cords, or cologne that contains alcohol. The nurse should keep the client's door open or use a window to observe them at all times, not just every 2 hours.

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

Nursing Test Bank

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