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 ["B","E","F","H","I"]
Explanation
A. The WBC count was not provided in the nurse’s notes or diagnostic section. Without any indication of infection or abnormal lab values, there is no basis to report WBC.
B. Although the pain level is mild (2/10), it may be contributing to anxiety, increased heart rate (110/min), and elevated BP (158/96 mm Hg). Report in context as part of a comprehensive assessment. Also, confirming that the pain is not worsening or atypical in nature is essential preoperatively.
C. The abdomen is soft, rounded, non-distended, with no tenderness, and active bowel sounds in all four quadrants — all normal postoperative readiness findings for abdominal surgery.
D. Knowing the blood type is routine pre-op procedure and is not an abnormal or urgent finding that needs immediate reporting. It is only relevant if transfusion is anticipated, which is not suggested here.
E. The client is requesting further details about the risks and benefits of surgery, which raises a legal and ethical concern about informed consent. The provider must ensure the client fully understands the procedure, otherwise surgery cannot proceed.
F. This is significantly elevated compared to baseline (126/74). Pre-op hypertension can increase surgical and anesthesia risk and should be evaluated further. It may be due to anxiety, pain, or another condition.
G. Platelet count values were not given in the scenario. Without abnormal lab results or bleeding concerns, there is no indication to report this.
H. This is lower than the previous baseline (97%). An SpO₂ < 94% on room air can signal underlying respiratory issues, atelectasis, sedation effects, or cardiac dysfunction, all of which should be addressed preoperatively.
I. The client ate breakfast at 0730 before a scheduled procedure, violating NPO (nothing by mouth) protocol. This significantly increases the risk of aspiration under anesthesia and must be reported immediately. The surgery may need to be rescheduled.
J. Capillary refill < 2 seconds is normal, indicating adequate peripheral perfusion. No issues with circulation are noted, so there's no reason to notify the provider.
Correct Answer is C
Explanation
A. "The lower end of the sling goes below the client's calves." The lower end of the sling should support the thighs and buttocks but typically does not extend below the calves. Positioning the sling incorrectly can cause discomfort or injury during the lift.
B. "The sides of the sling are for the client to hold on to." While some slings have loops for the caregiver to grasp, clients usually do not hold onto the sling sides during the lift, as this could interfere with safe handling and stability.
C. "This type of device is useful for a client who cannot assist." Mechanical lifts are specifically designed to safely transfer clients who have little or no ability to assist with moving. This reduces injury risk for both client and caregiver and ensures safe mobility.
D. "The device requires the client to use upper body strength." Mechanical lifts minimize the need for client effort, especially upper body strength. They are intended for clients unable to bear weight or assist, so reliance on client strength contradicts the device’s purpose.
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