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","D","E"]

Explanation

A. A diet low in phosphorus is not typically indicated for liver cirrhosis; instead, a low sodium diet is recommended to manage edema and ascites.

B. Noting signs of swelling and edema is important as these are common complications of cirrhosis due to hypoalbuminemia and portal hypertension.

C. Increasing oral fluid intake is not advised as it can exacerbate fluid accumulation in the abdomen (ascites) and peripheral tissues.

D. Monitoring abdominal girth helps in assessing the progression of ascites, which is a common complication of cirrhosis.

E. Reporting serum albumin and globulin levels is crucial as they provide information on the liver's synthetic function and the severity of liver disease.

A. Secure chest tube to the stretcher for transport. B. Administer PRN pain medication prior to transport. C. Mark the amount of chest drainage on the container. D. Keep chest tube container below the site of insertion.

Correct Answer is D

Explanation

A. Securing the chest tube to the stretcher is important, but not the most critical action as it does not directly affect the function of the chest tube during transport.
B. Administering pain medication is important for comfort but is not the most immediate concern during urgent transport for a CT scan.

C. Marking the amount of chest drainage is a routine monitoring action and can be done before or after transport, thus not the most critical action.
D. Keeping the chest tube container below the site of insertion is crucial to maintain proper
drainage by gravity and prevent complications such as tension pneumothorax, which can be life- threatening.

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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

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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

Correct Answer is D

Explanation

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