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 A

Explanation

Choice A reason: applying the client's positive airway pressure device can help prevent or reduce episodes of apnea and hypopnea during sleep by keeping the airway open and delivering oxygen. The nurse should ensure that the device fits properly and that the client knows how to use it.

Choice B reason: elevating the head of the bed to a 45 degree angle is not as effective as using a positive airway pressure device for a client with OSA. Elevating the head of the bed may help reduce snoring and improve breathing, but it may not prevent airway collapse or oxygen desaturation.

Choice C reason: removing dentures or other oral appliances is not as important as applying a positive airway pressure device for a client with OSA. Removing dentures or other oral appliances may help prevent choking or aspiration, but it may not prevent airway collapse or oxygen desaturation.

Choice D reason: lifting and locking the side rails in place is not as important as applying a positive airway pressure device for a client with OSA. Lifting and locking the side rails in place may help prevent falls or injuries, but it may not prevent airway collapse or oxygen desaturation.

A. Which medication works best for you? B. When do you hear voices? C. How do you cope with the voices? D. What are the voices saying?

Correct Answer is D

Explanation

Choice A reason: Which medication works best for you? This is not the most important question, as it does not address the current status or risk of the client. The medication history is a part of the assessment, but it does not help identify the content or impact of the hallucinations.

Choice B reason: When do you hear voices? This is not the most important question, as it does not address the current status or risk of the client. The frequency and timing of the hallucinations are a part of the assessment, but they do not help identify the content or impact of the hallucinations.

Choice C reason: How do you cope with the voices? This is not the most important question, as it does not address the current status or risk of the client. The coping strategies are a part of the assessment, but they do not help identify the content or impact of the hallucinations.

Choice D reason: What are the voices saying? This is the most important question, as it addresses the current status and risk of the client. The content and impact of the hallucinations are a part of the assessment, as they can help identify if the client is experiencing command hallucinations, which may instruct them to harm themselves or others.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with obstructive sleep apnea (OSA) ambulates in the hallway with the nurse prior to bedtime and then returns to bed. Which intervention is most important for the nurse to implement before leaving the client?

Correct Answer is A

Explanation

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to ask in the assessment of this client?

Correct Answer is D

Explanation

In caring for a client who is receiving meropenem IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider?

A patient who is hypotensive is receiving dopamine, an adrenergic agonist IV at the rate of 6 mcg/kg/min. Which intervention should the nurse implement when administering this medication?

A male client reports to the on-call clinic nurse that he took two tablets of 10 mg lisinopril by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any chest pain at the moment or recently. Which action should the nurse take?

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply.)

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. Theclient is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?

A male client reports to the on-call nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or recent chest pain. Which action should the nurse take?