A nurse is preparing to administer enteral medication to a client who has a gastrostomy tube. Which of the following actions should the nurse take first?
Flush the tube with water.
Measure stomach contents.
Elevate the head of the bed.
Return gastric content into the gastrostomy tube.
The Correct Answer is B
A. Flushing the tube with water is necessary after checking residual stomach contents to clear the tube, but measuring stomach contents comes first to ensure the tube is clear for proper medication administration.
B. Measuring stomach contents is crucial before administering enteral medication to confirm the tube's placement and ensure medication reaches the stomach appropriately, preventing complications such as aspiration.
C. Elevating the head of the bed is important during and after enteral feeding to prevent aspiration, but it is not the first action before medication administration.
D. Returning gastric content into the gastrostomy tube may be necessary after assessing and managing residual stomach contents, but it is not the initial step in medication administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While filling out an incident report may be necessary in some cases, it is not the initial action when a client refuses medication.
B. Reporting the incident to the provider is essential for nurses to follow proper protocols to ensure patient safety and compliance with healthcare regulations.
C. Returning the opened medication to the medication cart is not advisable due to potential medication errors and contamination risks.
D. Notifying the facility's ethics committee is not necessary for a routine medication refusal scenario.
Correct Answer is C
Explanation
A. Decreased temperature is a symptom of hypothyroidism, not hyperthyroidism which would indicate an overdose of levothyroxine.
B. Weight gain is more commonly associated with hypothyroidism, not hyperthyroidism caused by an overdose of levothyroxine.
C. Tachycardia (rapid heart rate) is a classic sign of hyperthyroidism, which can occur if the client's dose of levothyroxine is too high.
D. Bradypnea (slow breathing) is not typically associated with thyroid hormone overdosage.
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