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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
In this scenario, the dentist is increasing the amount of dairy products in her diet with the aim of reducing the risk of gingivitis due to her family history of cancer. However, the practical nurse (PN) should respond by suggesting that an increase in fruits and vegetables would be more beneficial.
Fruits and vegetables are rich in essential vitamins, minerals, and antioxidants, which can help support overall oral health and reduce the risk of gingivitis. They provide a wide range of nutrients that are important for maintaining healthy gums and teeth.
While dairy products can contribute to overall dental health due to their calcium content, they should not be solely relied upon as the primary means of preventing gingivitis or reducing the risk of cancer. A well- rounded and balanced diet, including plenty of fruits and vegetables, is essential for optimal oral health.
Options b, c, and d are not directly related to the dentist's concern about gingivitis and the increased consumption of dairy products. Encouraging exercise (option b) is generally beneficial for overall health, but it does not specifically address gingivitis. Reminding the client to ensure dairy products are fortified with vitamin D (option c) is not necessary in this context, as the focus is on preventing gingivitis rather than addressing vitamin D deficiency. Providing written information about the warning signs of cancer (option d) is not directly relevant to the dentist's current situation and concern about gingivitis.
Correct Answer is A
Explanation
When a client refuses to look at their mastectomy incision and refuses to talk about it, the best response by the practical nurse (PN) is to respect the client's autonomy and validate their feelings. Option a) acknowledges the client's discomfort and provides reassurance that it is okay for them to decline to look or talk about the incision at the moment. It also offers support by letting the client know that the incision will be available for examination when they feel ready to do so.
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