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 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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Correct Answer is A

Explanation

The correct answer is A. Electroconvulsive therapy (ECT) is a procedure that uses a mild electrical current to cause a brief seizure in the brain, which can help treat severe mentalhealth conditions. One of the possible side effects of ECT is short-term memory loss, which usually resolves within a few weeks. Therefore, if the client states that they might have short-term memory loss after the procedure, they indicate an understanding of the procedure and its risks. The other statements are incorrect or irrelevant. ECT does not require a full-liquid diet, a urinary catheter, or cause seizures after the procedure.

A. Urine specific gravity B. Prealbumin C. Temperature D. Bowel sounds

Correct Answer is A

Explanation

Choice A reason:

Urine specific gravity is the measurement of the concentration of solutes in urine and is an important indicator of the client's hydration status and kidney function. A specific gravity of 1.035 is relatively high, suggesting concentrated urine. High urine specific gravity can be a sign of dehydration or other kidney-related issues.

Reporting this finding to the provider is crucial because it could indicate potential problems with the client's fluid balance and kidney function. The provider may need to assess further, conduct additional tests, or initiate appropriate interventions to address the client's hydration and renal status.

Choice B reason:

Prealbumin: A prealbumin level of 25 mg/dL is within the normal range (usually 15-35 mg/dL) and may not require immediate reporting to the provider. Prealbumin is used to assess nutritional status, and this result suggests that the client's nutritional status is within the normal range.

Choice C reason:

Temperature: The provided information does not include any data about the client's temperature, and there are no signs of infection mentioned. Unless there are specific signs or symptoms of fever or infection, reporting the temperature is not necessary based on the given data.

Choice D reason

Bowel sounds: The provided information does not include any data about the client's bowel sounds, and there are no indications of gastrointestinal issues or abnormalities. Bowel sounds may not be relevant to report unless there are specific symptoms or signs of GI disturbances.

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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

Naxlex Comprehensive Predictor Exams

A nurse in an inpatient mental health facility is reinforcing teaching with a client who signed a consent form for electroconvulsive therapy. Which of the following statements by the clientindicates an understanding of the procedure?

Correct Answer is A

Explanation

A nurse is reviewing the medical record of a client. Which of the following findings should the nurse report to the provider? These are the medical report: Urine specific gravity 1.035, albumin 4.5 mg/L, prealbumin 25 mg/dL and potassium 4.2 mg/dL

Correct Answer is A

Explanation

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