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 A
Explanation
Choice A rationale:
Using a firm-bristled toothbrush can increase the risk of gum injury or bleeding, especially in individuals with pernicious anemia who may have fragile gums due to vitamin B12 deficiency. This choice is correct because it identifies a risk factor for injury.
Choice B rationale:
Prescribing vitamin B12 intramuscularly (IM) is the appropriate treatment for pernicious anemia and does not increase the client's risk of injury. It is essential for addressing the underlying deficiency.
Choice C rationale:
Prescribing epoetin intravenously (IV) is used to stimulate the production of red blood cells and treat anemia, but it is not typically associated with an increased risk of injury. However, it should be administered as ordered by the healthcare provider.
Choice D rationale:
Sleeping 8 to 10 hours per night is beneficial for overall health and well-being. It does not increase the client's risk of injury. In fact, adequate sleep can help with tissue repair and overall recovery.
Correct Answer is A
Explanation
Choice A rationale:
Elevating the head of the client's bed for 1 hour after the feeding is the correct choice because it helps reduce the risk of aspiration. Elevating the head of the bed at a 30-45 degree angle can promote the flow of enteral feeding solution into the jejunum, reducing the risk of reflux into the stomach and subsequent aspiration.
Choice B rationale:
Administering the feeding solution at a cold temperature is not recommended. Enteral feedings should be given at or near room temperature to prevent discomfort and cramping in the client.
Choice C rationale:
Rotating the jejunostomy tube once per day is not a standard practice. The tube should be secured in place to prevent dislodgement, but routine rotation is not necessary.
Choice D rationale:
Flushing the tube with 90 mL of sterile water before and after the feeding is not necessary for intermittent bolus enteral feedings. Flushing before and after continuous feedings may be required to maintain patency, but for intermittent bolus feedings, it is not a routine practice.
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