The nurse is reviewing the client's medical record.

Exhibits

The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

A. Apply water-soluble lubricant to the site. Lubricants are not necessary for gastrostomy tube site care. Instead, the nurse should keep the area clean and dry to prevent irritation and infection. Applying lubricant could increase moisture, potentially leading to skin breakdown or fungal infections.
B. Attach an extension tube to the site's opening prior to use. Extension tubes are only needed for certain types of gastrostomy devices, such as low-profile buttons, and should be attached only when feeding or administering medications. Continuous attachment is unnecessary and may increase the risk of dislodgment or contamination.
C. Tape the tube to the child's cheek. Taping a gastrostomy tube to the cheek is inappropriate, as it does not provide adequate stabilization and may cause discomfort. This technique is more commonly used for securing nasogastric tubes rather than gastrostomy tubes.
D. Secure the tubing to the child's abdomen. Properly securing the gastrostomy tube to the abdomen helps prevent accidental dislodgment, irritation, and skin breakdown. The tube should be secured with tape or a securement device while allowing slight movement to reduce tension on the insertion site.

A. Ask the facility chaplain to visit the client. While spiritual support can be beneficial, the nurse should first acknowledge and respect the client’s decision. Offering a chaplain visit without the client's request may not align with their personal beliefs or needs.
B. Discuss alternative treatment methods with the client. End-stage kidney disease has limited treatment options beyond dialysis or kidney transplantation. If the client has already decided to stop dialysis, discussing alternatives may not be appropriate unless the client expresses interest. The priority is to support their decision and provide comfort-focused care.
C. Tell the client she should discuss this decision with her family. While family involvement can be helpful, the decision to continue or stop dialysis is ultimately the client’s right. Encouraging discussion is appropriate, but the nurse should not imply that the client must consult others before making a personal healthcare decision.
D. Support the client's decision to stop the treatment. Autonomy is a fundamental ethical principle in nursing. Clients have the right to make their own healthcare decisions, including the choice to discontinue dialysis. The nurse should offer emotional support, provide palliative care options, and ensure the client’s comfort during the transition.