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.

Answer and Explanation

Correct Answer : A,B,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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Correct Answer is ["A","B","F"]

Explanation

A. Dietary intake: The client ate toast at 0600 and experienced vomiting. Since general anesthesia is typically used for an appendectomy, recent food intake increases the risk of aspiration and should be reported immediately to the surgical team.

B. Pain level: The client reports increasing pain (now 8/10) with rebound tenderness. This may indicate worsening inflammation or risk of rupture, which requires reassessment and potentially expedited surgical intervention.

C. Blood pressure: The blood pressure of 124/80 mm Hg is within normal limits and does not require follow-up before surgery. It reflects stable hemodynamics.

D. Informed consent: The provider has already obtained informed consent and placed it in the medical record. No further follow-up is needed unless the client withdraws consent or shows signs of confusion.

E. Oxygen saturation: The client's oxygen saturation is 96% on room air, which is acceptable. There are no indications of respiratory compromise that require further intervention preoperatively.

F. Allergies: The client reports allergies to shellfish, latex, and penicillin. These pose serious risks during surgery (e.g., anaphylaxis to latex gloves or antibiotics) and must be addressed in the preoperative checklist to ensure appropriate substitutes are used.

A. Wait for 4 hr before sending the specimen to the laboratory. B. Avoid collecting the specimen from areas of the stool that contain blood. C. Transfer the specimen to a cup without it touching the outside of the container. D. Collect at least 7.62 cm (3 in) of the client's stool.

Correct Answer is C

Explanation

A. Wait for 4 hr before sending the specimen to the laboratory: Delaying the transport of stool specimens can affect test results by allowing bacterial growth or degradation of components. Specimens should be sent promptly or refrigerated if there is a delay.

B. Avoid collecting the specimen from areas of the stool that contain blood: If testing for occult blood or infection, areas with blood should be included because they provide important diagnostic information, so avoiding them is incorrect.

C. Transfer the specimen to a cup without it touching the outside of the container: Maintaining specimen integrity and preventing contamination is essential. The nurse should ensure the stool does not contact the outside of the container to avoid spreading pathogens and ensure accurate testing.

D. Collect at least 7.62 cm (3 in) of the client's stool: Collecting such a large amount is unnecessary; usually a smaller amount (about 1 inch or walnut size) is sufficient for testing, so this choice is incorrect.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is scheduled for an appendectomy. Exhibits The nurse is assisting with preparing the client for surgery. Select the 3 findings that require follow-up prior to surgery.

Correct Answer is ["A","B","F"]

Explanation

A nurse is preparing to collect a stool specimen from a client for laboratory testing. Which of the following actions should the nurse take when collecting the specimen?

Correct Answer is C

Explanation

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