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 ["B","D","E"]
Explanation
Choice A reason: Providing diet low in phosphorus is not a relevant intervention for a client with cirrhosis of the liver. Phosphorus is a mineral that helps maintain bone health and acid-base balance. Cirrhosis of the liver does not affect phosphorus levels, but it can cause low calcium levels due to impaired vitamin D metabolism. The nurse should provide a diet high in calcium and vitamin D to prevent osteoporosis and fractures.
Choice B reason: This is a correct answer because noting signs of swelling and edema is an important intervention for a client with cirrhosis of the liver. Cirrhosis of the liver is a chronic condition that causes scarring and damage to the liver tissue, impairing its function and blood flow. This can lead to portal hypertension, which is increased pressure in the portal vein that carries blood from the digestive organs to the liver. Portal hypertension can cause fluid accumulation in the abdomen (ascites) and legs (peripheral edema). The nurse should assess the client's weight, fluid intake and output, abdominal girth, and extremity circumference.
Choice C reason: Increasing oral fluid intake to 1,500 mL daily is not a suitable intervention for a client with cirrhosis of the liver. Fluid intake should be individualized based on the client's fluid status, electrolyte levels, and urine output. Increasing fluid intake may worsen fluid retention and electrolyte imbalance in clients with cirrhosis of the liver. The nurse should restrict fluid intake to 1,000 to 1,500 mL daily or as prescribed by the healthcare provider.
Choice D reason: This is a correct answer because monitoring abdominal girth is an essential intervention for a client with cirrhosis of the liver. Abdominal girth is a measurement of the circumference of the abdomen at the level of the umbilicus. It reflects the amount of fluid in the peritoneal cavity, which can increase due to portal hypertension and hypoalbuminemia in clients with cirrhosis of the liver. The nurse should measure and record abdominal girth daily or more frequently as indicated.
Choice E reason: This is a correct answer because reporting serum albumin and globulin levels is a significant intervention for a client with cirrhosis of the liver. Albumin and globulin are types of proteins that are synthesized by the liver and have various functions in the body, such as maintaining fluid balance, transporting hormones and drugs, and fighting infections. Cirrhosis of the liver can cause low albumin levels due to reduced synthesis and increased loss through ascites or urine. Low albumin levels can cause edema, malnutrition, and increased risk of infection. Cirrhosis of the liver can also cause high globulin levels due to chronic inflammation or immune response. High globulin levels can indicate autoimmune diseases, infections, or malignancies. The nurse should monitor and report serum albumin and globulin levels as they reflect liver function and overall health status.
Correct Answer is A
Explanation
Choice A reason: Moderate amount of foul-smelling lochia. This is the most indicative finding of a postpartum infection, as it suggests that the client has endometritis, which is an inflammation of the uterine lining. Endometritis is a common cause of maternal morbidity and mortality, and requires prompt antibiotic treatment.
Choice B reason: Blood pressure of 122/74 mm Hg. This is a normal blood pressure for a postpartum client, and does not indicate an infection. The reference range for blood pressure is 90/60 to 140/90 mm Hg.
Choice C reason: Oral temperature of 100.2°F (37.9°C). This is a slightly elevated temperature for a postpartum client, but it does not necessarily indicate an infection. The reference range for oral temperature is 97.6 to 99.6°F (36.4 to 37.6°C). A mild fever may occur in the first 24 hours after delivery due to dehydration or hormonal changes.
Choice D reason: White blood cell count of 19,000/mm³ (19 x 10⁹/L). This is a high white blood cell count for a postpartum client, but it does not indicate an infection. The reference range for white blood cell count is 5,000 to 10,000/mm³ (5 to 10 x 10⁹/L). A leukocytosis may occur in the first few days after delivery due to stress or tissue injury.
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