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 a continuous feeding via gastrostomy tube (GT).
Which instruction is most important for the PN to emphasize?
Raise the entire bed while bathing the client to reduce back strain
Report any drainage observed around the GT insertion site
Keep the head of the bed raised while the tube feeding is infusing
Use plenty of pillows to position the client on the side after bathing.
The Correct Answer is C
Answer is c. Keep the head of the bed raised while the tube feeding is infusing.
The client has a gastrostomy tube (GT), which is a tube inserted through the abdomen into the stomach for feeding purposes1. The PN should instruct the UAP to keep the head of the bed raised at least 30 degrees while the tube feeding is infusing, to prevent aspiration of the feed into the lungs2. Aspiration can cause pneumonia, which is a serious complication that can be fatal3.
a. Raising the entire bed while bathing the client to reduce back strain is not the most important instruction, because it does not address the risk of aspiration. The PN should also consider the client’s comfort and safety when adjusting the bed height. b. Reporting any drainage observed around the GT insertion site is not the most important instruction, because it is not directly related to the tube feeding. Drainage may indicate infection or leakage of the feed, which should be reported and managed accordingly. d. Using plenty of pillows to position the client on the side after bathing is not the most important instruction, because it is not specific to the tube feeding. Positioning the client on the side may help prevent pressure ulcers and improve circulation, but it does not prevent aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Facial erythema (redness of the face) is not a typical manifestation of pertussis (whooping cough) Pertussis primarily presents with a severe cough, often followed by a "whooping" sound during inhalation, and can cause complications like pneumonia and apnea. Facial erythema is not a characteristic sign of the disease.
Choice B rationale:
A beefy, red tongue is not a common manifestation of pertussis. This description is more suggestive of other conditions, such as vitamin deficiencies or certain infections. Pertussis primarily involves respiratory symptoms, and a red tongue is not a typical finding associated with the disease.
Choice C rationale:
Fever is a common manifestation of pertussis, and it is often one of the early symptoms. However, it is not the most specific sign of the disease, as many other infections can also cause fever. While fever can occur in pertussis, it is not the most distinctive feature of the condition.
Choice D rationale:
Koplik spots are not associated with pertussis but rather with measles (rubeola) Koplik spots are small white or grayish-blue spots with a red halo that appear on the mucous membranes inside the cheeks and are characteristic of measles. Pertussis is primarily known for its characteristic cough and paroxysms of coughing, not for Koplik spots.
Correct Answer is C
Explanation
Choice A rationale:
Replacing the ear molds once per year is not a standard recommendation for hearing aid maintenance. The frequency of ear mold replacement may vary depending on individual needs and wear and tear. It is not necessary to replace them annually unless there is a specific issue with the ear molds.
Choice B rationale:
Disinfecting the hearing aid with isopropyl alcohol is not recommended for routine cleaning. Isopropyl alcohol can damage the components of the hearing aid, including the microphone and receiver. Cleaning solutions specifically designed for hearing aids or a soft cloth are safer options for routine cleaning.
Choice C rationale:
Cleaning the hearing aid with a soft cloth is the correct action to take when caring for hearing aids. Routine cleaning with a soft cloth helps remove dust, debris, and earwax from the hearing aid's surface without causing damage to the components. It is a safe and effective method of maintaining hearing aid hygiene.
Choice D rationale:
Changing the battery once per month is not a fixed rule for all hearing aids. The frequency of battery replacement depends on the type of hearing aid, battery size, and individual usage patterns. Some batteries may last longer than a month, while others may need replacement sooner. Clients should be instructed to replace the battery when it no longer functions effectively.
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