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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Countertransference is not the appropriate concept in this scenario. Countertransference refers to the nurse's emotional response to the client, which may be based on the nurse's unresolved issues and can negatively affect the therapeutic relationship. In this case, the nurse's actions are not driven by unresolved issues but by a desire to meet the client's basic needs.
Choice B rationale: Promoting trust is the most suitable explanation for the nurse's actions. By interrupting the bath and providing a healthy meal to a newly admitted client who hasn't eaten all day, the nurse is demonstrating empathy, compassion, and a commitment to meeting the client's physiological needs. This action helps build trust between the nurse and the client, as the client can see that their well-being is a priority.
Choice C rationale: Boundary crossing refers to actions that may blur or violate professional boundaries between a nurse and a client. While the nurse is going beyond the routine bath to provide a meal, this action is justified by the client's immediate need and doesn't constitute an inappropriate boundary crossing. The nurse is still maintaining professionalism in caring for the client.
Choice D rationale: Veracity is the principle of truth-telling and honesty in healthcare. It doesn't directly apply to this situation since the nurse's actions are not about providing information or disclosing something to the client. Instead, the nurse's primary concern is the client's nutritional well-being.
Correct Answer is D
Explanation
Choice A rationale:
Ice cream. Ice cream is not typically recommended for individuals with irritable bowel syndrome (IBS) as it contains dairy, which can exacerbate gastrointestinal symptoms in some people with lactose intolerance or dairy sensitivity. It may also be high in sugar, which can worsen IBS symptoms for some individuals.
Choice B rationale:
Honey. Honey is generally well-tolerated by individuals with IBS and can be used as a natural sweetener in moderation. However, it is not specifically recommended as a dietary inclusion for managing IBS symptoms.
Choice C rationale:
Watermelon. Watermelon is a low-fiber fruit that may be well-tolerated by some individuals with IBS, especially during periods of symptom flare-ups. However, it does not provide the beneficial probiotics and digestive enzymes found in yogurt, which can be helpful for some IBS patients.
Choice D rationale:
Yogurt. Yogurt, especially varieties containing live probiotic cultures, can be beneficial for individuals with IBS. Probiotics may help improve gut health and alleviate some gastrointestinal symptoms associated with IBS. It is often recommended as a dietary inclusion for those with IBS.
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