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

The correct answer is: B. Secure the tubing with adhesive tape to the lower abdomen.

Choice A rationale: Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine reflux, which can lead to urinary tract infections (UTIs).

Choice B rationale: Securing the tubing with adhesive tape to the lower abdomen is correct as it helps to prevent accidental pulling or tugging on the catheter, maintaining its position and reducing the risk of dislodgement.

Choice C rationale: Collecting a sterile specimen from the urinary drainage bag is incorrect. Specimens should be collected from the sampling port, not directly from the drainage bag, to ensure sterility.

Choice D rationale: Coiling the tubing on the bed above the collection bag is incorrect as it can cause urine to flow back into the bladder, increasing the risk of infection.

A. Assign the client to a negative pressure airflow room. B. Administer aspirin if the client develops a fever. C. Have visitors remain at least 0.91 m (3 feet) away from the client. D. Initiate contact precautions for the client.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale: Assigning the client to a negative pressure airflow room is crucial as varicella zoster is highly contagious and can be transmitted through airborne droplets. A negative pressure room helps contain the virus and filters the air, reducing the risk of spread to other patients and healthcare personnel.

Choice B rationale: Administering aspirin is contraindicated in clients with varicella zoster due to the risk of Reye's syndrome, especially in children and adolescents. Aspirin should not be given to children or adolescents with viral infections because it can cause serious complications affecting the liver and brain.

Choice C rationale: Having visitors remain at least 0.91 m (3 feet) away from the client is insufficient. Varicella zoster is highly contagious and requires more stringent airborne precautions, including having visitors wear masks and follow proper hygiene protocols to minimize the risk of transmission.

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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?