The client is a young male who appears to be 25-30 years old. He was found unconscious on a sidewalk by a jogger who was passing. The jogger called an ambulance, and the EMT's transported the ent to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT CT of the head in the emergency room showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.

The PN reinforces education about seizures to the client and asks him to explain what he understands about his condition.

Which statements indicate understanding?

Select all that apply

A. Reporting any drainage observed around the gastrostomy tube insertion site is important for monitoring potential infection or complications; however, it is not the most immediate concern during a total bed bath.
B. While using plenty of pillows to position the client on the side after bathing is important for comfort and skin integrity, it does not address the safety of the feeding during the bath.
C. Keeping the head of the bed raised while the tube feeding is infusing is the most critical instruction. This position helps prevent aspiration and ensures that the feeding is administered safely while maintaining the client’s airway during the bathing process.
D. Raising the entire bed while bathing the client is helpful for the caregiver's ergonomics but does not take precedence over ensuring the client’s safety regarding the gastrostomy tube feeding.

The presence of a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor indicates the possibility of infection in the wound. Evaluating the client's C-reactive protein (CRP) level can provide information about the presence and severity of inflammation and infection. CRP is an acute-phase reactant produced by the liver in response to inflammation. An elevated CRP level suggests an active inflammatory process, which can help in determining the need for further assessment and treatment, such as wound cultures or antibiotics.
Here's why the other options are incorrect:

B- Serum blood glucose (BG) level: While diabetes and elevated blood glucose levels can increase the risk of infection and delay wound healing, in this case, the presentation of redness, swelling, drainage, and odor suggests a possible wound infection. Evaluating the client's blood glucose level is important for the overall management and control of diabetes, but it is not the first priority when assessing a potentially infected wound.
C- Serum albumin: Serum albumin is a measure of the client's nutritional status and can provide information about the client's overall protein levels. While malnutrition can affect wound healing, in this scenario, the priority is to assess for signs of infection and inflammation. Addressing the wound infection takes precedence over evaluating the client's serum albumin level.
D- Culture for sensitive organisms: Obtaining a wound culture for sensitive organisms may be necessary to identify the specific bacteria causing the infection and determine the appropriate antibiotic treatment. However, before performing a wound culture, it is important to assess the severity of the wound infection and determine the need for further intervention. Evaluating the client's CRP level is a more immediate and readily available assessment to determine the presence and severity of inflammation.