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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Collecting fingerstick glucose levels is the most important intervention for the PN to implement for a client who is receiving TPN. TPN is a method of feeding that bypasses the gastrointestinal tract and provides all the nutritional needs of the body through a vein. TPN contains a high concentration of glucose, which can cause hyperglycemia or ﬂuctuations in blood sugar levels. Therefore, it is essential to monitor the client's glucose levels frequently and adjust the infusion rate or insulin administration accordingly.

A. Ask to see the client's list of home medications B. Determine if the client has recently lost a loved one C. Measure the client's vital signs D. Collect a sputum and urine culture and sensitivities E. Perform a 12-lead electrocardiogram F. Have the client ambulate across the room. G. Ask about the client's last bowel movement H. Measure the client's abdominal circumference

Correct Answer is ["A","B","C","E","H"]

Explanation

To identify the potential source of the client's new-onset confusion and decreased appetite, the nurse can use the following assessment techniques:

Ask to see the client's list of home medications: This can help identify any medications that may contribute to confusion or appetite changes.
Determine if the client has recently lost a loved one: Emotional distress, such as grief from a recent loss, can contribute to changes in mental status and appetite.
Measure the client's vital signs: Vital signs can provide important information about the client's overall health status and help identify any abnormalities that may be contributing to the symptoms.
Perform a 12-lead electrocardiogram: This can help assess the client's cardiac function and detect any cardiac-related causes for the symptoms.
Ask about the client's last bowel movement: Changes in bowel habits can sometimes be indicative of underlying issues affecting appetite and overall health.
Measure the client's abdominal circumference: This can help assess for any abdominal distension or changes that may be related to the client's symptoms.

Incorrect answers

Collecting a sputum and urine culture and sensitivities and having the client ambulate across the room are not directly related to identifying the potential source of confusion and decreased appetite in this case.

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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?

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Naxlex Comprehensive Predictor Exams

Which intervention is most important for the practical nurse (PN) to implement for a client who is receiving total parenteral nutrition (TPN)?

Correct Answer is A

Explanation

Exhibits Review H and P and nurse's notes. What other assessment techniques can the nurse use to identify the potential source of the client's new-onset confusion and decreased appetite? Select all that apply.

Correct Answer is ["A","B","C","E","H"]

Explanation

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