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 B
Explanation
Choice A rationale:
Fever. Fever is not an adverse effect of hypoglycemia. Fever is usually associated with an elevated body temperature, often due to infection or other inflammatory conditions, and is not directly related to low blood sugar levels.
Choice B rationale:
Shakiness. Shakiness is a common symptom of hypoglycemia. When blood sugar levels drop too low, the body responds with symptoms like trembling or shakiness, which is caused by the release of stress hormones like epinephrine. These symptoms are the body's way of signaling the need for immediate glucose intake to raise blood sugar levels.
Choice C rationale:
Increased urination. Increased urination is not a typical symptom of hypoglycemia. In fact, frequent urination may be associated with hyperglycemia (high blood sugar levels) in conditions like diabetes mellitus.
Choice D rationale:
Thirst. Thirst is not a direct symptom of hypoglycemia. Thirst is more commonly associated with hyperglycemia, where high blood sugar levels lead to increased urine output, causing dehydration and subsequent thirst. In hypoglycemia, the focus is on correcting the low blood sugar levels rather than managing thirst.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
Clamp chest tube when client ambulates. Contraindicated. Clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition. The chest tube should be kept open and patent at all times, unless ordered by the provider for a specific reason. Report burning pain in chest to provider. Indicated.
Burning pain in the chest may indicate an infection, inflammation, or injury to the pleura or lung tissue. The provider should be notified of any changes in the client’s pain or discomfort.
Reinforce dressing around the tube as needed if it loosens. Indicated. The dressing around the chest tube should be kept dry and intact to prevent air leaks and infection. If the dressing becomes loose, wet, or soiled, it should be reinforced with sterile gauze and tape.
Strip the tubing twice daily to ensure patency. Contraindicated. Stripping or milking the tubing can cause increased negative pressure in the chest cavity, which can damage the lung tissue and impair gas exchange. The tubing should be assessed for kinks, clots, or obstructions, and gently tapped or repositioned if needed.
Maintain chest tube below the chest. Indicated. The chest tube should be kept below the level of the chest to facilitate drainage by gravity and prevent backflow of fluid into the pleural space.
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