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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
A. Prick the side of the client's finger: Pricking the side (lateral aspect) of the fingertip reduces discomfort and provides good blood flow compared to the center of the finger, making it the preferred site for capillary blood sampling.
B. Squeeze the client’s finger until a blood drop forms: Squeezing or "milking" the finger vigorously after the prick can cause hemolysis (rupture of red blood cells) and dilute the specimen with interstitial fluid. This can lead to inaccurate results.
C. Elevate the client’s hand above the level of the heart: Elevating the hand above heart level can reduce blood flow to the finger, making it harder to obtain an adequate sample. The hand should be positioned at or slightly below heart level.
D. Apply clean gloves: Wearing clean gloves protects both the client and nurse from exposure to bloodborne pathogens and maintains infection control standards.
E. Cleanse the client’s finger with an iodine swab: Iodine is not typically used for capillary puncture site cleansing due to potential skin irritation and interference with some tests. An alcohol swab is preferred for cleaning before puncture.
Correct Answer is A
Explanation
A. Hyponatremia: Vomiting and diarrhea cause significant fluid loss, often leading to a decrease in sodium levels in the blood (hyponatremia) due to loss of electrolytes and dilution from fluid replacement or retained water.
B. Hyperkalemia: Vomiting and diarrhea usually cause potassium loss, resulting in hypokalemia rather than hyperkalemia, as potassium is lost through gastrointestinal fluids.
C. Hypocalcemia: Calcium levels are generally not directly affected by vomiting and diarrhea, so hypocalcemia is less likely in this scenario.
D. Hypermagnesemia: Magnesium is typically lost with gastrointestinal losses; therefore, hypermagnesemia is uncommon with vomiting and diarrhea.
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