During a bath, the unlicensed assistive personnel (UAP) reports to the nurse that the client has malodorous discharge from the gastrostomy tube.
The nurse should initially
During a bath, the unlicensed assistive personnel (UAP) reports to the nurse that the client has malodorous discharge from the gastrostomy tube.
The nurse should initially
A. obtain a specimen for culture.
[9%]
B. assess the drainage.
[76%]
C. place a sterile dressing around the gastrostomy tube.
[4%]
D. assess the client's temperature for fever.
[10%]
Statistics
Subject/Lesson
Subject
Leadership & Management
Lesson
Assignment/Delegation
Client Need
Test Plan
Physiological Adaptation
Related Topic
Illness Management
Item Type
Item Type
Application
Explanation
Choice B is correct. The nurse should assess the client's drainage before collecting a specimen for culture and notifying the physician. The nurse needs to validate the findings reported by the UAP before proceeding with other actions.
Choice A is incorrect. The nurse may need to culture the drainage to determine the causative organism. However, the initial action by the nurse is to validate the report by the UAP.
Choice C is incorrect. The nurse will need to apply a sterile drain sponge around the tube to absorb any drainage. Before dressing the site, the nurse needs to validate the report by the UAP and assess the site.
Choice D is incorrect. The nurse needs to validate the UAP report before assessing the client for systemic infection. The nurse should localize the assessment to the tube before broadly looking for a constitutional infection.
Related Videos
2 Key Topics
Scope of Practice Overview
15.7 Delegation
Additional Info
✓ Accurate and thorough documentation of the drainage characteristics is essential. Document the appearance, color, consistency, odor, and quantity of the drainage. Include the time of assessment and any changes observed over time.
✓ Effective communication is crucial. Notify the healthcare provider promptly if there are any concerns about the drainage, such as signs of infection or unusual changes. Document and report any client complaints or discomfort related to the drainage.
✓ Educate the client and their caregivers about the normal expectations for gastrostomy tube drainage, including its appearance and odor.
