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","C"]
Explanation
A. Family health history: A comprehensive family health history is crucial as it can reveal a pattern of certain diseases within a family. The client's parents both had heart disease, and his father had diabetes, which significantly increases the client's risk for these conditions.
B. Homosexual Lifestyle: This is not a risk factor for heart disease. Sexual orientation does not inherently increase the risk of heart disease. The inclusion of this option reflects a common misconception and is not medically relevant.
C. History of hypertension: Even though the client's blood pressure is currently managed with atenolol, a history of hypertension is a significant risk factor for heart disease. It's important to explore the duration and control of hypertension over time.
D. Vegetarian diet: Generally, a vegetarian diet is associated with lower risk factors for heart disease, such as reduced blood pressure and lower cholesterol levels. However, it's important to ensure that the diet is well-balanced and includes all necessary nutrients.
E.While exercise is generally beneficial for heart health, it is possible to overdo it. However, the client's episode occurred during jogging, which is typically a moderate form of exercise. Unless the client is engaging in extreme levels of exercise, this is unlikely to be a significant risk factor.
Correct Answer is C
Explanation
A. Notify the emergency response team of the client's seizure: While the seizure is significant, it lasted less than 1 minute and resolved spontaneously. There is no need to call an emergency response team unless complications arise or the seizure becomes prolonged.
B. Keep orienting the client to time and space until he is less confused: While supportive, this is not the priority. Postictal confusion is expected and does not usually require active reorientation until the client regains baseline status.
C. Explain the postictal state that usually follows seizures: Providing reassurance and education to the spouse about postictal symptoms (such as confusion, lethargy, and altered responsiveness) is appropriate and therapeutic. It addresses her concern while monitoring the client for further changes.
D. Ask the wife to wait outside the room until the nurse can talk with her: This action excludes the spouse unnecessarily and delays communication. Involving the family promotes trust and understanding.
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