A nurse is administering a liquid medication to a client who has an NG tube set to intermittent suction. Identify the sequence of steps the nurse should take when administering the medication. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) (ORDERED RESPONSE)
Check the client's gastric residual.
Verify the tube placement.
Pour the medication into the syringe and allow it to flow by gravity.
Clamp the NG tube for 20 to 30 min.
The Correct Answer is ["B","A","C","D"]
A. Check the client's gastric residual: After confirming tube placement, gastric residual is assessed to evaluate delayed gastric emptying, which could increase the risk of aspiration. This is done before administering medications or feedings.
B. Verify the tube placement: Tube placement is verified first to ensure the medication is delivered into the stomach and not the lungs. This prevents aspiration and other complications associated with incorrect tube placement.
C. Pour the medication into the syringe and allow it to flow by gravity: Once placement is confirmed and residual checked, the medication is administered via gravity through the syringe to minimize pressure on the NG tube and promote safe delivery.
D. Clamp the NG tube for 20 to 30 min: After administering the medication, the NG tube is clamped to allow for medication absorption before suction is resumed. Immediate suctioning would remove the medication before it can take effect.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Chlorine bleach: Chlorine bleach is the recommended disinfectant for cleaning surfaces contaminated with Clostridium difficile spores. It is effective in killing these hardy spores that are resistant to many other disinfectants.
B. Chlorhexidine: Chlorhexidine is an antiseptic commonly used for skin cleansing, not for disinfecting environmental surfaces contaminated with C. difficile. It is ineffective against spores.
C. Triclosan: Triclosan is an antimicrobial found in some personal care products, but it is not suitable or approved for disinfecting surfaces in healthcare settings, especially against C. difficile.
D. Isopropyl alcohol: Alcohol-based disinfectants are ineffective against C. difficile spores. They do not have sporicidal activity and are not recommended for cleaning in cases of C. difficile infection.
Correct Answer is D
Explanation
A. Mark the length to be inserted on the tube with tape: Marking the insertion length is important to ensure correct placement, but this step should occur after assessing which nare to use and preparing the client.
B. Instruct the client to hyperextend her neck: Hyperextending the neck is not recommended during NG tube insertion; instead, the client should slightly flex the neck to facilitate tube passage.
C. Place a water-based lubricant on the tip of the tube: Lubricating the tube reduces discomfort and eases insertion, but this step comes after selecting the nostril and preparing the client.
D. Compare the patency of the client’s nares: Assessing which nostril is more patent is the first priority to ensure the tube is inserted through the nare that offers the least resistance, reducing trauma and improving comfort during insertion.
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