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 ["A","B","E","F"]
Explanation
A. Maintain a safe and private environment for the client – Anticipated. Providing a secure and private setting helps support the client emotionally and ensures confidentiality during a sensitive situation.
B. Request a consult for case management – Anticipated. Case management can coordinate follow-up care, legal support, counseling, and additional resources for the client.
C. Provide resources to the client for the local Alcoholics Anonymous chapter – Contraindicated. There is no indication that the client has an alcohol use disorder. The focus should remain on addressing the sexual assault.
D. Contact children and youth services – Contraindicated. The client is a college student and an adult. There is no mention of minors being involved, so reporting to child protective services is unnecessary.
E. Provide resources for local support services – Anticipated. Connecting the client with crisis centers, advocacy groups, and counseling services is essential for emotional and psychological support.
F. Administer sexually transmitted infection prophylaxis – Anticipated. Post-exposure prophylaxis (PEP) for sexually transmitted infections (STIs), including gonorrhea, chlamydia, and HIV, should be administered to prevent potential infection.
Correct Answer is D
Explanation
A) Weight loss: Weight loss is not a sign of fluid overload; rather, it is more indicative of dehydration or insufficient nutritional intake. Fluid overload typically leads to weight gain due to the accumulation of excess fluid in the body, so weight loss would not be a manifestation of this condition.
B) Decreased skin turgor: Decreased skin turgor is a common sign of dehydration, not fluid overload. When a person is dehydrated, the skin loses its elasticity, and it takes longer to return to its normal position after being pinched. This is the opposite of what is seen in fluid overload, where excess fluid causes the skin to appear more swollen or taut.
C) Decreased blood pressure: Decreased blood pressure is more commonly associated with hypovolemia (low fluid volume) or dehydration, rather than fluid overload. In fluid overload, blood pressure may actually rise due to the increased volume of circulating blood, not decrease.
D) Crackles heard in the lungs: Crackles, or rales, heard in the lungs are a classic sign of fluid overload, particularly when the excess fluid accumulates in the lungs (pulmonary edema). This can occur due to the heart's inability to pump effectively, leading to fluid retention in the lungs. Therefore, crackles in the lungs are a key manifestation of fluid overload.
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