The charge nurse observes a new nurse demonstrate the administration of two different liquid medications through a gastrostomy tube used for continuous feedings Which action(s) should the charge nurse take? (Select all that apply)

Advise the nurse to use the plunger when giving medications.

Encourage the nurse to flush the tube with more water.

Confirm that the nurse determined the amount of gastric residual.

Instruct the nurse to administer each medication separately.

Add the liquid volumes when documenting fluid intake.

Answer and Explanation

Correct Answer : B,C,D,E

A. Advising the nurse to use the plunger when giving medications is not recommended as it can create too much pressure and potentially damage the gastrostomy tube or cause discomfort to the patient. It's important to allow the medication to flow by gravity to prevent these issues.

B. Encouraging the nurse to flush the tube with more water is correct because it helps to ensure that the medication is cleared from the tube and reduces the risk of clogging. Flushing with water also helps to maintain hydration for the patient.

C. Confirming that the nurse determined the amount of gastric residual is correct because it is essential to check for any undigested food or medication in the stomach before administering more. This helps to prevent aspiration and other complications.

D. Instructing the nurse to administer each medication separately is correct. This practice
prevents drug interactions within the tube and ensures that each medication is given correctly and has the intended effect.

E. Adding the liquid volumes when documenting fluid intake is correct because all fluids
administered, including medications, should be accounted for in the patient's fluid balance. This is crucial for monitoring and managing the patient's hydration status and overall health.

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Correct Answer is B

Explanation

A. Assigning the UAP to another client does not address the need for proper infection control measures when assisting the client with influenza.

B. Wearing a face mask is essential to prevent the transmission of respiratory droplets during close contact with the client with influenza. Reviewing the importance of wearing a face mask reinforces infection control practices.

C. Applying a fitted respirator mask may not be necessary for routine care of a client with influenza and may not be readily available for UAP use.

D. While important, monitoring the client's respiratory status does not directly address the need for infection control measures to prevent the spread of influenza.

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

A. Determining the patient's need for pain medication is a priority to ensure the patient's comfort during the end-of-life care process. Pain management is a critical aspect of palliative care and should be addressed promptly.
B. Updating the nurse manager on the patient's status is important but is not the immediate priority. The nurse manager's awareness does not directly impact the patient's comfort or care at the moment of impending death.
C. Conveying the patient's status to the chaplain may be part of the holistic care approach and can provide spiritual support to the patient and family, but it is not the first priority in terms of the patient's immediate physical needs.
D. Documenting the impending signs of death is essential for legal and medical records; however, it is secondary to addressing the patient's immediate needs, such as pain relief.

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The charge nurse observes a new nurse demonstrate the administration of two different liquid medications through a gastrostomy tube used for continuous feedings Which action(s) should the charge nurse take? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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