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 D
Explanation
The correct answer is d. To cremate the client’s body.
Choice A reason: This choice is incorrect because Hinduism does not generally prohibit medical personnel from touching the deceased’s body. In fact, it is customary for family members to prepare the body for cremation, which may include washing and dressing.
Choice B reason: This statement is incorrect as there is no specific tradition in Hinduism that requires the family to stay with the body for 8 hours following death.
Choice C reason: This option is incorrect because Hinduism typically does not prescribe burial within 24 hours of death. While some religions have specific time frames for burial, Hinduism generally prefers cremation over burial.
Choice D reason: This is the correct choice. Cremation is preferred in Hinduism and is usually performed as soon as possible, traditionally by the next day. It is believed to release the soul and help in its onward journey.
Correct Answer is D
Explanation
The correct answer is choiced. “Limit the number of choices for the client.”
Choice A rationale:
Using written signs to assist the client with locating the bathroom can be helpful, but it is not the most critical strategy for managing Alzheimer’s disease.
Choice B rationale:
Providing a stimulating environment for the client can sometimes lead to overstimulation, which may increase confusion and agitation in clients with Alzheimer’s disease.
Choice C rationale:
Using confrontation to manage the client’s behavior is not recommended as it can lead to increased agitation and aggression.
Choice D rationale:
Limiting the number of choices for the client helps reduce confusion and anxiety, making it easier for them to make decisions and feel more in control.
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