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?
Report any drainage observed around the GT insertion site.
Use plenty of pillows to position the client on the side after bathing.
Keep the head of the bed raised while the tube feeding is infusing.
Raise the entire bed while bathing the client to reduce back strain.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. C-reactive protein level:
C-reactive protein (CRP) is a marker of inflammation but does not specifically identify the causative organism of an infection. While elevated CRP can suggest infection or inflammation, it doesn't provide the necessary information for treatment.
B. Serum blood glucose (BG) level:
Serum blood glucose levels are important to monitor in diabetic patients because high glucose levels can impair healing and increase the risk of infection. However, it does not directly help identify the causative organism in this situation.
C. Serum albumin:
Serum albumin reflects nutritional status and can indicate malnutrition or poor wound healing. While it may be relevant for healing, it is not the most immediate test to evaluate for infection.
D. Culture for sensitive organisms:
Given the red, swollen wound with drainage and foul odor, a wound culture is the most appropriate first step to identify the specific infectious organism. This will guide the healthcare provider in selecting the most appropriate antibiotic treatment.
Correct Answer is C
Explanation
When the practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) consistently records subnormal temperatures when using the thermometer, the first action the PN should take is to observe how the UAP obtains temperatures. This allows the PN to directly assess the UAP's technique and determine if any errors or inaccuracies are occurring during temperature measurement. By observing the process, the PN can identify any potential issues, such as incorrect placement of the thermometer or improper technique, and provide appropriate guidance and education.
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