A nurse has administered 5 mL of medication to a client via NG tube. They used 30 mL of water to flush the tube both before and after the instillation. The nurse should document which of the following amounts as liquid intake for the client?
65 mL
5 mL
35 mL
60 mL
The Correct Answer is A
A. 65 mL: The total liquid intake includes 30 mL of water used to flush the NG tube before the medication, 5 mL of medication instilled, and 30 mL of water used to flush the tube afterward. Adding these together gives 65 mL, which accurately reflects all fluids administered.
B. 5 mL: Documenting only the medication omits the water used for flushing, underrepresenting the client’s total fluid intake.
C. 35 mL: This amount accounts only for the post-flush water and medication, it ignores the pre-flush water, resulting in an inaccurate intake record.
D. 60 mL: This underestimates the total intake by failing to include all three components correctly; precise documentation is essential for fluid balance monitoring.
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Related Questions
Correct Answer is D
Explanation
A. 15°: This angle is used for intradermal injections, such as a tuberculin skin test, where the medication is deposited just under the epidermis. It would not allow the needle to reach the muscle layer, making it inappropriate for intramuscular administration.
B. 60°: An angle of 60° is not a standard technique for any specific injection type. At this angle, the medication would likely end up in the subcutaneous tissue instead of the muscle, leading to improper absorption and reduced effectiveness.
C. 45°: This angle is appropriate for subcutaneous injections, such as insulin, when a shorter needle is used or in thin clients. It does not penetrate deeply enough to reach the muscle tissue for intramuscular medication administration.
D. 90°: A 90° angle ensures the needle penetrates through the subcutaneous tissue and into the muscle, which is necessary for intramuscular injections. This angle allows the medication to be deposited directly into the muscle for proper absorption and therapeutic effect.
Correct Answer is D
Explanation
A. Strong, bounding pulse: Hypokalemia causes weak, thready, or irregular pulses due to its effects on cardiac muscle excitability. A strong, bounding pulse is more characteristic of hypervolemia or other cardiovascular conditions.
B. Positive Chvostek's sign: A positive Chvostek’s sign is associated with hypocalcemia, not hypokalemia. It indicates neuromuscular excitability due to low calcium levels.
C. Hyperactive reflexes: Hypokalemia generally causes muscle weakness, fatigue, and diminished or hypoactive reflexes rather than hyperactive reflexes.
D. Decreased bowel sounds: Low potassium levels reduce smooth muscle excitability in the gastrointestinal tract, leading to decreased peristalsis and hypoactive bowel sounds, which is a common finding in hypokalemia.
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