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 B
Explanation
After a hip arthroplasty with prosthesis placement, it is important to follow specific precautions to protect the surgical site and prevent dislocation of the hip joint. One common precaution is to avoid excessive internal rotation, adduction, and f
The other observations mentioned in the scenario are correct and demonstrate appropriate knowledge of the turning procedure:
A. Placing an abduction pillow between the client's legs helps maintain proper alignment and prevents adduction of the legs, which can cause hip dislocation.
C. Keeping the back straight and knees bent when moving the client promotes proper body mechanics and reduces the risk of injury to the UAPs.
D. Using a turning sheet under the client for turning and repositioning helps reduce friction and shearing forces, making the process safer and more comfortable for the client.
Correct Answer is ["C","E"]
Explanation
C. Regularly selects salty snacks to eat in the evening: Consuming excessive amounts of sodium (found in salty snacks) can increase blood pressure and contribute to the development of hypertension.
E. Chews tobacco while playing baseball every weekend: Tobacco use, including chewing tobacco, is associated with an increased risk of hypertension and other cardiovascular diseases.
The other choices are incorrect because they do not directly contribute to an increased risk of hypertension:
A. Drinks a protein supplement for breakfast every day: Consuming a protein supplement for breakfast does not necessarily increase the risk of hypertension. However, it is important to note that some protein supplements may contain added sodium, which can contribute to hypertension if consumed in excessive amounts.
B. Eats eight ounces of nonfat yogurt for lunch daily: Eating nonfat yogurt is generally considered a healthy food choice. However, unless the yogurt is high in added sodium, it would not significantly increase the risk of hypertension.
D. Walks briskly for two miles every day after work: Regular exercise, such as brisk walking, is generally beneficial for cardiovascular health and can help lower blood pressure. It is unlikely to increase the risk of hypertension.
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