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 {"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.

A. Syringe B. Tongue depressor C. Adhesive tape D. Cotton-tipped applicator

Correct Answer is A

Explanation

A. Syringe: A syringe is essential for irrigating a stage 4 pressure injury to cleanse the wound thoroughly without causing trauma to the tissue. Proper irrigation helps remove debris and bacteria, promoting healing. A syringe allows controlled, gentle flushing of the wound bed, which is important in managing deep, complex wounds like stage 4 pressure injuries.

B. Tongue depressor: A tongue depressor is generally used to examine the throat and oral cavity and is not suitable for wound care. It lacks the precision and safety needed for wound cleaning or dressing application, especially for deep pressure ulcers.

C. Adhesive tape: Adhesive tape is used to secure dressings but is not a primary supply for wound care itself. In managing a stage 4 pressure injury, the priority is proper wound cleaning and dressing materials rather than just securing them, so adhesive tape is secondary.

D. Cotton-tipped applicator: Cotton-tipped applicators are commonly avoided in wound care because they can leave fibers in the wound bed and potentially cause trauma or infection. They are not recommended for cleaning or applying medication to deep pressure ulcers, where more sterile, gentle methods are needed.

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Naxlex Comprehensive Predictor Exams

A nurse in a rehabilitation facility is assisting in the care of a client who was admitted the previous day. Exhibits Complete the following sentence by using the list of options. The client is at risk for dropdown as evidenced by the client's dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?

Correct Answer is A

Explanation

A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?

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