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

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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Correct Answer is B

Explanation

A. Tortuous veins: Tortuous veins indicate varicosities, which are typically a chronic condition and not an immediate sign of deep-vein thrombosis (DVT). While they can be associated with venous insufficiency, they do not require urgent reporting for DVT suspicion.

B. Calf swelling: Calf swelling, especially if unilateral, is a classic sign of DVT and suggests venous obstruction by a thrombus. This finding requires prompt reporting to prevent complications such as pulmonary embolism.

C. Bradycardia: Bradycardia is unrelated to DVT and is not an expected finding in this condition. It does not indicate thrombotic complications and does not require immediate reporting in this context.

D. Clammy skin: Clammy skin can be a nonspecific sign related to many conditions such as shock or anxiety but is not a primary indicator of DVT. It does not necessitate urgent reporting for DVT unless accompanied by other concerning signs.

A. Tell the client to think about something else. B. Tell the client that everything will be okay. C. Ask the client to describe their support system. D. Ask the client why they're unable to cope.

Correct Answer is C

Explanation

A. Tell the client to think about something else: Redirecting the client's thoughts without addressing their emotional distress can be dismissive. It does not support emotional processing or help the nurse assess the client’s coping needs.

B. Tell the client that everything will be okay: Offering false reassurance minimizes the client’s feelings and may hinder open communication. It does not validate their experience or help develop coping strategies.

C. Ask the client to describe their support system: Exploring the client’s support system helps assess available emotional and practical resources. This information is essential in planning appropriate interventions and enhancing coping capacity.

D. Ask the client why they're unable to cope: "Why" questions can make clients feel defensive and judged. It is more therapeutic to use open-ended questions that invite sharing without implying blame.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is collecting data from a client who reports an inability to cope because of their recent job loss. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assisting in the care of a client in a provider's office. Exhibits A nurse is caring for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe? Select all that apply.

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