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","B","E"]

Explanation

A. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty. Rationale: This task is within the scope of practice for a practical nurse, who can monitor and report changes in a patient's vital signs postoperatively.

B. Perform daily surgical dressing change for a client who had an abdominal hysterectomy.
Rationale: A practical nurse is trained to perform dressing changes, which is a routine postoperative care task.
C. Initiate patient controlled analgesia (PCA pumps for two clients immediately
postoperatively. Rationale: This task is typically reserved for registered nurses as it requires assessment and specialized knowledge in pain management.
D. Start the second blood transfusion for a client twelve hours following a below knee amputation. Rationale: Initiating blood transfusions is generally the responsibility of a registered nurse due to the complexity and potential complications involved.
E. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). Rationale: A practical nurse can administer medications, including insulin, as per the sliding scale protocol under the supervision of a registered nurse.

A. Provide diet low in phosphorus. B. Note signs of swelling and edema. C. Increase oral fluid intake to 1,500 mL daily. D. Monitor abdominal girth. E. Report serum albumin and globulin levels.

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

Explanation

A. A diet low in phosphorus is not typically indicated for cirrhosis of the liver. Cirrhosis primarily affects the body's ability to handle proteins and not phosphorus.
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 retention and ascites, which are complications of cirrhosis.
D. Monitoring abdominal girth is crucial for assessing changes in ascites and potential fluid overload.
E. Reporting serum albumin and globulin levels is essential as these can indicate the severity of liver disease and help guide treatment.

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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

The nurse is caring for a group of clients with the help of a practical nurse (PN) Which nursing action(s) should the nurse assign to the PN? (Select all that apply)

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

Explanation

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

Explanation

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