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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Uncapped sharps being put in a puncture-resistant container (choice A) is a safe and appropriate practice for the disposal of sharp objects, such as needles. This choice demonstrates adherence to infection control principles and minimizes the risk of accidental needlestick injuries.

Choice B rationale:

Soiled linens being placed on the floor (choice B) is not a safe or acceptable practice. Placing soiled linens on the floor can lead to contamination of the environment and pose a risk of spreading infection. Proper linen disposal protocols should be followed, which may include using designated linen hampers or containers.

Choice C rationale:

Waste containers being lined with single bags (choice C) is a standard practice for waste disposal. Using single bags makes it easier to handle and dispose of waste materials safely. It is a recommended infection control measure.

Choice D rationale:

Dampened cloths being used for dusting the area (choice D) is generally a safe practice for cleaning and dusting surfaces. Dampened cloths can help prevent the spread of dust and allergens. However, it's essential to ensure that the cloths are cleaned and disinfected regularly to prevent bacterial growth.

A. Pulled-pork sandwich. B. Shrimp salad. C. Roasted salmon. D. Clam chowder.

Correct Answer is C

Explanation

Choice A rationale:

A pulled-pork sandwich is not appropriate for a client following a kosher diet, as pork is not considered kosher due to dietary restrictions in Jewish dietary law (kashrut)

Choice B rationale:

Shrimp salad is not suitable for a client following a kosher diet, as shellfish is not considered kosher according to Jewish dietary laws.

Choice C rationale:

Roasted salmon is an appropriate choice for a client following a kosher diet, as salmon is typically considered kosher, provided it has been prepared and cooked according to kosher guidelines.

Choice D rationale:

Clam chowder is not appropriate for a client following a kosher diet, as it contains shellfish (clams), which is not considered kosher in Jewish dietary law.

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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 a continuous feeding via gastrostomy tube (GT). Which instruction is most important for the PN to emphasize?

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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 a continuous feeding via gastrostomy tube (GT).

Which instruction is most important for the PN to emphasize?