The charge nurse observes a new nurse during the administration of two different liquid medications at once through a gastrostomy tube used for enteral feeding. The charge nurse observes the new nurse's actions, as seen in the video.
What action(s) should the charge nurse take? (Select all that apply.)
Encourage the novice to flush the tube with more water.
Instruct the novice to administer each medication separately.
Add the liquid volumes when documenting fluid intake.
Confirm that the novice determined the amount of gastric residual.
Advise the novice to use the plunger when giving medications.
Correct Answer : A,B,D
Choice A reason: This is a correct answer because flushing the tube with more water is important to prevent clogging and maintain hydration. The novice should flush the tube with at least 15 mL of water before and after each medication, and between medications if more than one is given.
Choice B reason: This is a correct answer because administering each medication separately is important to prevent interactions and ensure accurate dosing. The novice should not mix different medications in one syringe or container, but give them one at a time, followed by water flushes.
Choice C reason: This is not a correct answer because adding the liquid volumes when documenting fluid intake is not necessary. The liquid medications do not count as fluid intake, but as medication administration. The novice should document the type, dose, route, and time of each medication given, as well as any adverse effects or complications.
Choice D reason: This is a correct answer because confirming that the novice determined the amount of gastric residual is important to assess tolerance and prevent aspiration. The novice should aspirate the gastric contents with a syringe before giving any medication or feeding, and measure and document the volume. If the volume is more than 100 mL or the prescribed amount, the novice should hold the medication or feeding and notify the healthcare provider.
Choice E reason: This is not a correct answer because advising the novice to use the plunger when giving medications is not recommended. The novice should use gravity to deliver the medications through the tube, by holding the syringe upright and allowing the liquid to flow slowly. Using the plunger can cause too much pressure and damage the tube or cause discomfort to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Increasing oxygen to 6 liters/minute is not an intervention that the nurse should implement, as this can worsen the bronchospasm and hypoxia by reducing the hypoxic drive and causing carbon dioxide retention. This is a contraindicated choice.
Choice B reason: Calling for an Ambu resuscitation bag is not an intervention that the nurse should implement, as this is not indicated for a client who is conscious and breathing spontaneously. This is an overreaction choice.
Choice C reason: Instructing the client to lie back in bed is not an intervention that the nurse should implement, as this can increase respiratory distress and compromise airway clearance by reducing lung expansion and increasing abdominal pressure. This is another contraindicated choice.
Choice D reason: Administering a nebulizer treatment is an intervention that the nurse should implement, as this can deliver bronchodilators and anti-inflammatory agents directly to the airways and improve ventilation and oxygenation for this client. Therefore, this is the correct choice.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: This is incorrect because instructing the client and family to reconsider end of life choices is disrespectful and insensitive. The nurse should respect the client's autonomy and preferences and support their decisions.
Choice B reason: This is correct because teaching the client how to use guided imagery is a helpful intervention for coping with feelings related to death and dying. Guided imagery is a relaxation technique that involves visualizing positive images and scenarios that can reduce stress, anxiety, and pain.
Choice C reason: This is correct because recording the client's desire to live is an important intervention for coping with feelings related to death and dying. The nurse should acknowledge and validate the client's emotions and help them express their hopes and fears.
Choice D reason: This is correct because encouraging family to visit frequently is a beneficial intervention for coping with feelings related to death and dying. The nurse should facilitate family involvement and communication and help the client maintain meaningful relationships.
Choice E reason: This is correct because encouraging family to bring the client old photographs is a useful intervention for coping with feelings related to death and dying. The nurse should assist the client in reminiscing and reviewing their life story and achievements.
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