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 A

Explanation

A. Ensure that the infant's crib mattress is firm. Rationale: A firm mattress reduces the risk of SIDS as it prevents the infant's face from sinking into the mattress, which could obstruct
breathing.
B. Prop the infant with a pillow when in a side-lying position. Rationale: Pillows should not be used with infants due to the risk of suffocation and increased risk of SIDS.
C. Swaddle the infant in a blanket for sleeping. Rationale: While swaddling can be comforting, it should be done correctly to avoid too tight swaddling, which can lead to overheating, another SIDS risk factor.
D. Place the infant in a prone position whenever possible. Rationale: Infants should be placed on their backs to sleep, not on their stomachs, as back-sleeping is associated with a decreased risk of SIDS. Prone sleeping positions are discouraged.

A. Replace the IV site with a smaller gauge B. Apply soft bilateral wrist restraints C. Leave the lights on in the room at night D. Redress the abdominal incision

Correct Answer is D

Explanation

A. Replacing the IV site with a smaller gauge does not address the issue of the client picking at the dressing and tape. It is important to address the primary concern, which is the integrity of the abdominal incision dressing.

B. Applying wrist restraints should be avoided unless absolutely necessary due to the risk of physical and psychological harm to the client. It is not the first-line intervention for addressing dressing and tape disruption.

C. Leaving the lights on in the room at night may help reduce confusion in some clients with dementia but does not address the immediate issue of the disrupted abdominal dressing and IV site.

D. Redressing the abdominal incision is the priority intervention to maintain the integrity of the surgical site and prevent infection. It also addresses the issue of the client picking at the dressing and tape, which could lead to further complications.

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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

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Correct Answer is A

Explanation

Correct Answer is D

Explanation

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