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 ["A","D"]
Explanation
S3 is an extra heart sound that occurs during diastole (the filling phase of the cardiac cycle). It is commonly associated with conditions such as heart failure and volume overload. S3 is often described as a low-frequency, dull, and distant sound heard after S2 (the second heart sound).
B, C- S1, and S2 are the normal heart sounds that are typically heard in all individuals. S1 is the first heart sound, heard as "lub," and is caused by the closure of the mitral and tricuspid valves. S2 is the second heart sound, heard as "dub," and is caused by the closure of the aortic and pulmonic valves. These sounds are normal and expected.
S4 is another abnormal heart sound, which occurs during late diastole and is associated with conditions such as ventricular hypertrophy and reduced ventricular compliance.
Correct Answer is C
Explanation
A. A heart rate of 120 beats/minute in a 2-month-old infant is within the expected normal range, so there is no immediate need to alert the charge nurse. Routine findings should be documented and managed according to standard protocol.
B. Digoxin should be withheld in infants if the apical heart rate is below 90–110 beats/minute depending on age. Since the infant’s heart rate is within the normal range, withholding the medication is not indicated.
C. Digoxin can be safely administered because a heart rate of 120 beats/minute is appropriate for a 2-month-old infant. Documenting the heart rate ensures accurate recording of the assessment prior to administration and supports safe medication practice.
D. There is no indication to delay or recheck the heart rate in 1 hour because the current rate is within normal limits. Delaying medication could interfere with therapeutic management.
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