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 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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Correct Answer is ["A","B","D"]

Explanation

The correct answer is: a. Paper tape, b. Small gauze pad, and d. Exam gloves.

Choice A: Paper tape

Reason: Paper tape is used to secure the gauze pad over the site after the saline lock is removed. It is gentle on the skin and helps to keep the gauze in place, preventing any bleeding or infection at the site.

Choice B: Small gauze pad

Reason: A small gauze pad is essential to apply pressure to the site after the saline lock is removed. This helps to stop any bleeding and provides a clean, sterile covering for the site.

Choice C: Sterile gloves

Reason: Sterile gloves are not necessary for this procedure. Exam gloves are sufficient to maintain cleanliness and prevent infection during the removal of the saline lock.

Choice D: Exam gloves

Reason: Exam gloves are used to maintain hygiene and prevent infection during the procedure. They provide adequate protection for both the nurse and the patient.

Choice E: Three mL syringe

Reason: A three mL syringe is not required for the removal of a saline lock. Syringes are typically used for flushing the saline lock, not for its removal.

A. Wheeze. B. Rhonchi. C. Stridor. D. Fine crackles.

Correct Answer is A

Explanation

Based on the provided audio clip, the sound heard is a high-pitched, continuous, musical sound. This sound is characteristic of wheezing, which is caused by the narrowing of the airways due to inﬂammation, bronchoconstriction, or the presence of mucus. Wheezing is commonly associated with conditions such as asthma, chronic obstructive pulmonary disease (COPD), or bronchitis.

Let's evaluate the other options:

b) Rhonchi: Rhonchi are low-pitched, coarse, ratling sounds that typically indicate the presence of mucus or ﬂuid in the larger airways. Rhonchi are often heard in conditions such as pneumonia or bronchitis, but they are diﬀerent from the high-pitched wheezing sound heard in the audio clip.

c) Stridor: Stridor is a high-pitched, harsh, and crowing sound that is heard during inspiration. It is often associated with upper airway obstruction, such as in cases of croup, epiglottitis, or a foreign body obstruction. The sound in the audio clip does not match the characteristics of stridor.

d) Fine crackles: Fine crackles are discontinuous, high-pitched, and brief sounds that are typically heard during inspiration. They are often described as "velcro-like" or "rice crispies" and are associated with conditions such as pulmonary fibrosis or congestive heart failure. The sound in the audio clip does not resemble fine crackles.

In summary, the sound in the provided audio clip is best described as wheezing, characterized by a high- pitched, continuous, musical sound. Therefore, the practical nurse (PN) should document this sound as "wheeze."

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

The practical nurse (PN) is auscultating a client's lung sounds. Which description should the PN use to document this sound? (Please listen to the audio clip provided). Audio: [Wheezing sound]

Correct Answer is A

Explanation

A client who had a knee replacement surgery and received a prescription for enoxaparin 30 mg subcutaneously every 12 hours for 10 days. The medication is available in 30 mg per 0.3 mL pre-filled syringes. How many mL should the practical nurse (PN) administer each day? (Enter numerical value only.)

A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. Which response should the practical nurse (PN) make?

The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using a tympanic thermometer. Which action should the PN take first?

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?

The parents of a one-year-old child with the diagnosis of hypospadias informed the practical nurse (PN) that they plan to delay corrective surgery to see if the child will outgrow the problem. Which information should the PN provide to these parents?

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