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 a continuous feeding via gastrostomy tube (GT).
Which instruction is most important for the PN to emphasize?
Raise the entire bed while bathing the client to reduce back strain
Report any drainage observed around the GT insertion site
Keep the head of the bed raised while the tube feeding is infusing
Use plenty of pillows to position the client on the side after bathing.
The Correct Answer is C
Answer is c. Keep the head of the bed raised while the tube feeding is infusing.
The client has a gastrostomy tube (GT), which is a tube inserted through the abdomen into the stomach for feeding purposes1. The PN should instruct the UAP to keep the head of the bed raised at least 30 degrees while the tube feeding is infusing, to prevent aspiration of the feed into the lungs2. Aspiration can cause pneumonia, which is a serious complication that can be fatal3.
a. Raising the entire bed while bathing the client to reduce back strain is not the most important instruction, because it does not address the risk of aspiration. The PN should also consider the client’s comfort and safety when adjusting the bed height. b. Reporting any drainage observed around the GT insertion site is not the most important instruction, because it is not directly related to the tube feeding. Drainage may indicate infection or leakage of the feed, which should be reported and managed accordingly. d. Using plenty of pillows to position the client on the side after bathing is not the most important instruction, because it is not specific to the tube feeding. Positioning the client on the side may help prevent pressure ulcers and improve circulation, but it does not prevent aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Hydrogen peroxide. Hydrogen peroxide is not the recommended solution for disinfecting surfaces following a blood spill. While it can be used to clean wounds and may have some disinfectant properties, it is not as effective as bleach in destroying bloodborne pathogens.
Choice B rationale:
Bleach. Bleach is the appropriate choice for disinfecting surfaces contaminated with blood. A 10% bleach solution (1 part bleach to 9 parts water) is effective at killing bloodborne pathogens such as HIV and hepatitis B and C viruses. It should be used in healthcare settings to ensure proper disinfection after a blood spill.
Choice C rationale:
Isopropyl alcohol. Isopropyl alcohol is an effective disinfectant for some purposes, but it may not be as effective as bleach against bloodborne pathogens. It is commonly used for cleaning and disinfecting skin before medical procedures but is not the recommended choice for disinfecting surfaces following a blood spill.
Choice D rationale:
Chlorhexidine. Chlorhexidine is an antiseptic solution often used for skin disinfection before surgical procedures or invasive medical interventions. It is not typically used for disinfecting surfaces contaminated with blood.
Correct Answer is D
Explanation
The correct answer is choiced. “Limit the number of choices for the client.”
Choice A rationale:
Using written signs to assist the client with locating the bathroom can be helpful, but it is not the most critical strategy for managing Alzheimer’s disease.
Choice B rationale:
Providing a stimulating environment for the client can sometimes lead to overstimulation, which may increase confusion and agitation in clients with Alzheimer’s disease.
Choice C rationale:
Using confrontation to manage the client’s behavior is not recommended as it can lead to increased agitation and aggression.
Choice D rationale:
Limiting the number of choices for the client helps reduce confusion and anxiety, making it easier for them to make decisions and feel more in control.
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