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The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has continuous feeding via a gastrostomy tube (GT). Which instruction is most important for the PN to emphasize?

A.

Report any drainage observed around the GT insertion site.

B.

Use plenty of pillows to position the client on the side after bathing.

C.

Keep the head of the bed raised while the tube feeding is infusing.

D.

Raise the entire bed while bathing the client to reduce back strain.

Answer and Explanation

The Correct Answer is C

A. Reporting drainage around the GT site is important for monitoring for infection, but it is not the most critical safety measure during the bath.
B. Using pillows to position the client can provide comfort and support, but it does not prevent a serious complication.
C. Keeping the head of the bed raised during continuous tube feeding is essential to reduce the risk of aspiration, which is a priority safety concern.
D. Raising the bed can reduce back strain for the UAP, but client safety takes precedence over staff ergonomics in this context.


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Related Questions

Correct Answer is D

Explanation

A thready pulse refers to a pulse that is weak and difficult to palpate. It may disappear or weaken with light pressure. This can be an indication of decreased peripheral perfusion or reduced blood volume. By documenting the finding as "Thready pulse volume," the nurse is accurately describing the quality of the pulse and its response to light pressure.

Incorrect:

A. Missing pulse: A missing pulse would mean that the pulse is not palpable at all, even without applying pressure.
B. Light pressure applied to pulse: This is not a description of the pulse quality, but rather a description of the action taken to assess the pulse.
C. Pulse skips beats: This would mean that the pulse is irregular, with beats being missed or added. In this case, the pulse disappears when light pressure is applied and returns when the pressure is removed, which describes a thready pulse volume.

Correct Answer is A

Explanation

A. Washing the hair and skin daily with mild soap and warm water helps remove excess oil, dirt, and bacteria that can contribute to acne formation. Gentle cleansing is an appropriate first-line recommendation for adolescents with mild acne.

B. Eliminating specific foods such as chocolate or fried foods is not consistently supported by evidence as a primary treatment for acne. Diet may influence some individuals, but routine restriction of these foods is not a standard initial recommendation.

C. Squeezing or expressing blackheads can traumatize the skin, increase inflammation, and lead to scarring or infection. Harsh exfoliation may further irritate the skin and worsen acne.

D. Referral to a dermatologist may be necessary for severe or persistent acne. However, initial management for mild acne typically includes proper skin hygiene and over-the-counter measures before pursuing long-term prescription therapy.

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