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 D

Explanation

Choice A rationale:

Delaying the discussion about managing hair loss when the client has expressed concern is not the best approach. The nurse should provide information and support when the client seeks it.

Choice B rationale:

Discouraging the client from worrying about hair loss at this moment is not empathetic. The client's concerns should be acknowledged and addressed.

Choice C rationale:

Expressing empathy and relating to the client's emotional experience is a good practice, but it does not directly answer the client's question about managing hair loss.

Choice D rationale:

Offering to get information about head-covering options indicates an understanding of the client's concerns and provides a proactive solution. It shows empathy and willingness to support the client during chemotherapy, where hair loss can be a significant emotional issue.

A. Cause of the client's death. B. Last set of the client's vital signs. C. Copy of the client's advance directives. D. Location of the identification tag on the client's body.

Correct Answer is D

Explanation

The correct answer is: d. Location of the identification tag on the client’s body.

Choice A reason: The cause of the client’s death is determined by a physician or a medical examiner and is not typically documented by nurses in postmortem documentation. The cause of death is a medical determination that involves a complex process, including examination and possibly an autopsy.

Choice B reason: The last set of the client’s vital signs is relevant prior to death and is part of the end-of-life documentation. However, once the client has passed away, recording vital signs is no longer applicable and is not included in postmortem documentation.

Choice C reason: A copy of the client’s advance directives is an important document that outlines the client’s wishes regarding medical treatment and interventions. While it is crucial before the client’s death, it does not need to be included in postmortem documentation, as it serves no purpose after death.

Choice D reason: The location of the identification tag on the client’s body is a critical piece of information that must be included in postmortem documentation. This ensures that the body is correctly identified throughout the postmortem process, including during transfer to a mortuary or funeral home.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is to begin chemotherapy.The client asks the nurse about managing hair loss.Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

Correct Answer is D

Explanation

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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?