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 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.
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Related Questions
Correct Answer is D
Explanation
Gently blowing the nose helps to clear any mucus or debris from the nasal passages, allowing for better delivery and absorption of the medication. It also helps to ensure that the nasal passages are clear and open, allowing the medication to reach its intended target.
A. Deep breathing and coughing are unrelated to the administration of nasal spray and are not necessary before using the medication.
B. Checking glucose levels before and after administration is not relevant for fluticasone furoate nasal spray. Glucocorticoid nasal sprays are not typically associated with significant effects on blood glucose levels.
C. Exhaling through the mouth is not a specific action required before using the nasal spray. It may be a general instruction for some other respiratory therapies or procedures, but it is not directly related to the administration of the nasal spray.
Correct Answer is A
Explanation
- A terminally ill client is a client who has a progressive and incurable disease or condition that is expected to result in death within a short period of time, such as months or weeks. A terminally ill client may require palliative care, which is the care that focuses on relieving pain and suffering and improving the quality of life for the client and their family.
- An admission assessment is the process of collecting information about a client's health status, needs, preferences, and goals when they are admitted to a health care facility, such as a hospital, nursing home, or hospice. An admission assessment helps to establish a baseline for the client's condition, plan and implement appropriate interventions, and evaluate the outcomes of care.
- A health care proxy is a legal document that allows a client to appoint another person, such as a family member or a friend, to make health care decisions for them if they become unable to do so themselves. A health care proxy may also include specific instructions or preferences about the type and extent of care that the client wishes to receive or refuse, such as life-sustaining treatments, resuscitation, or organ donation.
- Health care proxy documentation is important information that the practical nurse (PN) should collect during the admission assessment of a terminally ill client to an acute care facility, as it reflects the client's autonomy, dignity, and wishes regarding their end-of-life care. It also helps to ensure that the client's healthcare decisions are respected and followed by the healthcare team and the facility.
- Therefore, option A is the correct answer, while options B, C, and D are incorrect.
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