A6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy, Which pre- operative nursing action has highest priority?

A. The tube should be flushed with at least 15–30 mL of water before, between, and after medication administration to prevent clogging and ensure full delivery of the medications.

B. Instructing the nurse to administer each medication separately is correct. This is important to prevent drug interactions within the tube and to ensure accurate dosing. Administering
medications separately allows for proper absorption and can prevent complications such as clogging of the tube.

C. Adding the liquid volumes when documenting fluid intake is correct. It is essential to account for all sources of fluid intake to maintain accurate fluid balance records. Medications
administered through a gastrostomy tube contribute to the patient's overall fluid intake and must be included in the documentation.

D. Confirming that the nurse determined the amount of gastric residual is correct. This is a critical step to ensure that the patient is tolerating the feedings and to prevent complications such as
aspiration. Gastric residual volume can indicate if the patient's digestive system is processing the feeding appropriately.

E. Advising the nurse to use the plunger when giving medications is not necessary in this context. The use of a plunger can be appropriate in some situations, but the scenario does not provide enough information to suggest that the nurse had difficulty administering the medications that would require the use of a plunger. Additionally, using a plunger can increase the risk of tube
damage or patient discomfort.

A. A diet low in phosphorus is not typically indicated for liver cirrhosis; instead, a low sodium diet is recommended to manage edema and ascites.

B. Noting signs of swelling and edema is important as these are common complications of cirrhosis due to hypoalbuminemia and portal hypertension.

C. Increasing oral fluid intake is not advised as it can exacerbate fluid accumulation in the abdomen (ascites) and peripheral tissues.

D. Monitoring abdominal girth helps in assessing the progression of ascites, which is a common complication of cirrhosis.

E. Reporting serum albumin and globulin levels is crucial as they provide information on the liver's synthetic function and the severity of liver disease.