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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Reinforcing need for adequate hydration is not the most important action for the nurse to implement, as this is a general recommendation for all clients and does not address the specific needs of this client. This is a distractor choice.

Choice B reason: Providing typed instructions for healthy diet selection is not the most important action for the nurse to implement, as this may not be feasible or accessible for this client who lives in a poor neighborhood and may have limited resources and literacy. This is another distractor choice.

Choice C reason: Scheduling follow-up appointments with specialists is the most important action for the nurse to implement, as this can ensure that this client receives continuous and comprehensive care for their complex and chronic conditions, which can improve their outcomes and quality of life. Therefore, this is the correct choice.

Choice D reason: Demonstrating specific breathing and walking exercises is not the most important action for the nurse to implement, as this can be done by other health care professionals or at home by the client. This is another distractor choice.

A. The patient's need for pain medication should be determined. B. The nurse manager should be updated on the patient's status. C. The patient's status should be conveyed to the chaplain. D. The impending signs of death should be documented.

Correct Answer is A

Explanation

Choice A reason: the nurse's priority is to provide comfort and dignity to the dying patient. Pain management is an essential aspect of end-of-life care.

Choice B reason: updating the nurse manager is not a priority action. The nurse manager can be informed later, after the patient's needs are met.

Choice C reason: conveying the patient's status to the chaplain is not a priority action. The chaplain can be contacted later, after the patient's needs are met. The chaplain may also need the consent of the patient or the family before providing spiritual support.

Choice D reason: documenting the impending signs of death is not a priority action. Documentation can be done later, after the patient's needs are met. Documentation is important, but not as important as providing comfort and dignity to the dying patient.

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Naxlex Comprehensive Predictor Exams

An adolescent from a poor neighborhood who has a history of severe chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD) is being discharged from a funded nursing facility. Which action is most important for the nurse to implement?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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