A nurse is preparing to administer 2 medications via client's NG tube. Which of the following actions should the nurse take?
Mix the 2 medications together prior to administration.
Add the medications to a small amount of theformula.
Flush the tube with at least 30 mL of sterile water prior to administering the medications.
Connect the NG tube to suction t min after administration of the medications.
The Correct Answer is C
A) Mix the 2 medications together prior to administration: It is not recommended to mix medications together before administering them through an NG tube unless specifically instructed by a healthcare provider or the pharmacy. Some medications can interact or precipitate when combined, which could reduce their effectiveness or cause harmful reactions. Therefore, it is safer to administer each medication separately, followed by a flush.
B) Add the medications to a small amount of the formula: Medications should not be mixed with enteral feeding formula, as it can affect the absorption of the medication and alter its effectiveness. Additionally, the medications could interact with components of the formula, leading to complications or reduced efficacy.
C) Flush the tube with at least 30 mL of sterile water prior to administering the medications: This is the correct action. Flushing the NG tube with 30 mL of sterile water before administering medications helps ensure the tube is clear and patent, preventing clogging. It also prepares the tube to receive the medications, ensuring proper delivery into the gastrointestinal tract.
D) Connect the NG tube to suction 10 minutes after administration of the medications: Connecting the NG tube to suction immediately after medication administration could remove the medications before they are absorbed. It is important to wait at least 30 minutes after administering medications before connecting the NG tube to suction to ensure the medication is absorbed adequately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Autonomy: Autonomy refers to the right of individuals to make their own choices and decisions. While the nurse’s actions may promote the client’s independence in the future, the nurse’s promise to walk with the client does not directly address or uphold the client’s autonomy. The nurse is offering support rather than encouraging the client to make independent decisions about their participation in the exercise.
B) Fidelity: Fidelity involves being faithful and keeping promises or commitments. In this scenario, the nurse promises to walk with the client in the courtyard each day, and this promise demonstrates the ethical principle of fidelity. The nurse is demonstrating trustworthiness and loyalty by committing to help the client overcome their anxiety and follow through with the daily exercise.
C) Justice: Justice is the ethical principle that focuses on fairness and equal treatment for all individuals. While justice is important in providing equal care to all clients, it is not the primary principle in this scenario. The nurse’s actions focus on meeting the specific needs of the individual client, which is more aligned with fidelity.
D) Nonmaleficence: Nonmaleficence means “do no harm.” While the nurse’s goal is to prevent harm by helping the client address their anxiety, the primary ethical principle at play here is fidelity, as the nurse is keeping their promise to provide consistent support. Nonmaleficence would be more relevant if the nurse were directly addressing potential harm or risk associated with the client’s situation, but the promise to walk with the client focuses more on the nurse’s commitment.
Correct Answer is A
Explanation
A) Facial erythema:
Facial erythema is commonly seen in children with pertussis due to the intense coughing fits that are characteristic of the disease. The child may experience bursts of violent coughing, which can lead to a flushed appearance, especially in the face, due to increased pressure during coughing. This manifestation is a common and expected sign in children with pertussis.
B) Peeling of the hands and feet:
Peeling of the hands and feet is not a typical manifestation of pertussis. This is more commonly associated with conditions such as toxic shock syndrome or Kawasaki disease. Pertussis primarily presents with respiratory symptoms such as coughing and a characteristic "whooping" sound, not peeling skin.
C) Fever:
While a mild fever may occur in some children with pertussis, it is not the most prominent symptom. Pertussis is more often characterized by severe coughing fits, which can cause vomiting and a distinctive "whooping" sound, particularly during the paroxysmal stage. Fever is typically mild and not the hallmark of the disease.
D) Beefy, red tongue:
A beefy, red tongue is not a typical finding in pertussis. This symptom is more commonly seen in conditions such as scarlet fever or vitamin B12 deficiency. Pertussis primarily presents with respiratory symptoms like severe coughing and difficulty breathing, and does not typically affect the tongue in this manner.
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