The charge nurse observes a new nurse during the administration of two different liquid medications at once through a gastrostomy tube used for enteral feeding. The charge nurse observes the new nurse's actions, as seen in the video. What action(s) should the charge nurse take? (Select all that apply.)

Encourage the novice to flush the tube with more water.

Instruct the novice to administer each medication separately.

Add the liquid volumes when documenting fluid intake.

Confirm that the novice determined the amount of gastric residual.

Advise the novice to use the plunger when giving medications.

Answer and Explanation

Correct Answer : A,B,C,D

The correct answer is A, B, C, and D.

Choice A reason: Flushing the gastrostomy tube with water is essential to maintain tube patency and prevent medication interactions. It should be done before and after medication administration. The typical amount of water used for flushing can range from 15 to 30 mL.

Choice B reason: Administering each medication separately is a critical practice to prevent drug interactions and ensure that the full dose of each medication is delivered. It also helps in preventing the clogging of the tube.

Choice C reason: Documenting all liquid volumes, including medications and water used for flushing, is important for accurate fluid intake records. This helps in maintaining fluid balance and monitoring the patient’s hydration status.

Choice D reason: Checking gastric residual volume is important to assess the patient’s tolerance to enteral feeding and to prevent complications such as aspiration. Normal gastric residual volumes are generally considered to be less than 250 mL.

Choice E reason: Using a plunger to administer medications through a gastrostomy tube is not always recommended. Medications should be administered slowly to prevent discomfort or harm, and the use of a plunger is not a standard practice across all healthcare settings.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice D is correct because frequent exposure to sunlight is the most significant environmental factor when planning care for a client with osteomalacia. Osteomalacia is a condition in which the bones become soft and weak due to inadequate mineralization, often caused by vitamin D deficiency. Vitamin D is essential for calcium absorption and bone health, and it can be synthesized by the skin when exposed to sunlight. The nurse should encourage the client to get at least 15 minutes of sunlight per day or take vitamin D supplements as prescribed.

Choice A is incorrect because quiet, calm surroundings are not a specific environmental factor for a client with osteomalacia. Quiet, calm surroundings may help reduce stress and promote relaxation, but they do not affect bone mineralization or vitamin D synthesis.

Choice B is incorrect because stimulating sounds and activity are not a specific environmental factor for a client with osteomalacia. Stimulating sounds and activity may help improve mood and cognition, but they do not affect bone mineralization or vitamin D synthesis.

Choice C is incorrect because cool, moist air is not a specific environmental factor for a client with osteomalacia. Cool, moist air may help relieve respiratory symptoms or allergies, but it does not affect bone mineralization or vitamin D synthesis.

A. Alcohol consumption will not produce vascular changes. B. Weight management is promoted by taking daily walks for thirty minutes. C. Salt substitutes can help with maintaining a healthy diet. D. Blood pressure readings should be taken at noontime. E. Sodium intake can be regulated by rinsing canned foods in water. F. Uncontrolled hypertension can lead to renal damage.

Correct Answer is ["B","C","E","F"]

Explanation

Choice B is correct because weight management is an important factor in preventing and controlling hypertension. Taking daily walks for thirty minutes can help reduce weight and lower blood pressure.

Choice C is correct because salt substitutes can help with maintaining a healthy diet by reducing sodium intake. Sodium intake is associated with increased blood pressure and should be limited to less than 2,300 mg per day.

Choice E is correct because sodium intake can be regulated by rinsing canned foods in water. Canned foods often contain high amounts of sodium as a preservative and rinsing them can remove some of the excess sodium.

Choice F is correct because uncontrolled hypertension can lead to renal damage. Hypertension can cause damage to the blood vessels and impair the function of the kidneys, leading to chronic kidney disease or failure.

Choice A is incorrect because alcohol consumption can produce vascular changes that increase blood pressure. Alcohol intake should be limited to no more than one drink per day for women and two drinks per day for men.

Choice D is incorrect because blood pressure readings should not be taken at noontime. Blood pressure readings should be taken at the same time each day, preferably in the morning before breakfast or in the evening before dinner.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which environmental factor is most significant when planning care for a client with osteomalacia?

Correct Answer is D

Explanation

The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply)

Correct Answer is ["B","C","E","F"]

Explanation

When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. Which action should the nurse take?

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donninggloves and a gown to assist the client. Which action should the nurse take?

The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first?

A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

The nurse is providing education to a client who experiences recurrent episodes of moderate anxiety to situations. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin 500 mg PO twice daily. Which statement(s) should the nurse include in this client’s teaching plan? (Select all that apply.)