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
Explanation
TPAL stands for Term, Premature, Abortion, and Living children, and it is used to document a client's obstetrical history.
In this case, the client has had a total of 5 pregnancies:
- Two pregnancies resulted in full-term (term) births, so the Term value is 2.
- Three pregnancies resulted in miscarriages during the first trimester (abortion), so the Abortion value is 3.
- The client has two living children, so the Living value is 2.
- There is no mention of any premature births, so the Premature value is 0.
Therefore, the appropriate documentation for this client's TPAL is Term 2, Premature 0, Abortion 3, and Living 2.
Correct Answer is B
Explanation
Hypoglycemia occurs when blood glucose levels drop below normal levels. It is commonly associated with diabetes mellitus and can result from various factors such as excessive insulin or oral hypoglycemic medication, delayed or missed meals, increased physical activity, or alcohol consumption.
Tremors, or shaking hands, are one of the early signs of hypoglycemia. They can occur due to the brain's response to low blood glucose levels. Other early signs of hypoglycemia may include sweating, palpitations, anxiety, hunger, and weakness.
A. Polyuria, or excessive urination, is not typically associated with hypoglycemia. It is more commonly seen in conditions such as hyperglycemia or diabetes insipidus.
C. Bradycardia, or a slow heart rate, is not a characteristic sign of hypoglycemia. It can occur in some cases of severe hypoglycemia, but it is not an early sign.
D. Difficulty swallowing is not directly related to hypoglycemia. It may be caused by other factors such as neurological or muscular conditions, esophageal disorders, or structural abnormalities in the throat or esophagus.
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