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. Removing blankets from the client helps reduce external heat sources and allows body heat to dissipate, which can aid in lowering the elevated temperature. This action supports the body’s natural cooling mechanisms and provides comfort during a febrile state.
B. Placing cold packs on the axillae can help lower body temperature by cooling major blood vessels near the skin’s surface. However, this method may cause discomfort or shivering, which can paradoxically increase metabolic heat production and is less preferred than removing excess coverings.
C. Using a fan to blow air across the client promotes evaporative cooling, but if the client is shivering or chills are present, this can increase discomfort and cause the body to generate more heat. Fans are best used when the client is comfortable and not experiencing chills.
D. Giving an alcohol sponge bath is generally discouraged because alcohol is rapidly absorbed through the skin and can cause toxicity. Additionally, it can cause vasodilation, which might lead to increased heat loss and potential hypothermia if not carefully monitored.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
- Aspiration: The client reports food getting stuck in the mouth and has a hoarse voice, which are classic signs of dysphagia (difficulty swallowing). Dysphagia significantly increases the risk for aspiration, where food or liquid enters the airway instead of the esophagus.
- Neurological status: The client also has left-sided weakness, suggesting a neurologic impairment (possibly from a stroke or similar event), which can affect swallowing coordination and airway protection.
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