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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Insufficient sleep, particularly due to nightmares, can exacerbate depression and should be addressed promptly.
Feeling "jumpy" or experiencing heightened anxiety, especially in situations reminiscent of the trauma, indicates a possible post-traumatic stress disorder (PTSD symptom.
A profound sense of sadness and numbness can be indicative of severe depression, requiring immediate attention.
Correct Answer is C
Explanation
A. Placing an indwelling urinary catheter and measuring strict intake and output may be necessary for comprehensive assessment and management but is not the priority action in this situation, which suggests a possible stroke.
B. Keeping the bed in the lowest position and initiating seizure and fall precautions are important for safety, but the client's symptoms are suggestive of a stroke, and immediate evaluation and potential treatment are needed.
C. Starting two large-bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is the priority action. The client's symptoms, including right-sided weakness and sluggish speech, suggest a potential ischemic stroke. IV fibrinolytic therapy (e.g., tissue plasminogen activator) is time-sensitive and may be indicated for eligible patients with acute ischemic stroke.
D. Maintaining elevated positioning of the dependent joints on the affected side is not the priority action in this situation. Immediate assessment and potential treatment for a suspected stroke are needed.
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