The client is a 26-year-old female who was in a car accident 6 months ago that killed her mother, husband, and 2-year-old

She and her father were the only survivors of the crash. She is seeking care for depression.

Click to highlight the areas that the nurse should react to immediately.

The client has returned to work at an accounting firm and has started going to a grief support group. She states she is seeking care from a healthcare professional because her father is worried about her. The client states she only gets 2-3 hours of sleep due to nightmares about the crash.

She states that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy after the accident, especially when she is in the car. She also stated, " feel so sad that I can't seem to feel anything at all." In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.

A. Obtain a capillary glucose level: The symptoms of jitteriness and tachypnea in a newborn could be indicative of hypoglycemia, so the first action should be to assess the glucose level to determine if hypoglycemia is the cause.

B. Feed 30 mL of 10% dextrose in water: While providing dextrose may be necessary if hypoglycemia is confirmed, assessing the glucose level should be done first to guide appropriate treatment.

C. Wrap tightly in a warm blanket: While keeping the newborn warm is important, it is not the first action to take in this scenario where the newborn is displaying signs of possible hypoglycemia.

D. Encourage the mother to breastfeeD Breastfeeding may help increase the newborn's glucose level, but the priority is to assess the glucose level first to determine if hypoglycemia is present.

A. The tube should be flushed with at least 15–30 mL of water before, between, and after medication administration to prevent clogging and ensure full delivery of the medications.

B. Instructing the nurse to administer each medication separately is correct. This is important to prevent drug interactions within the tube and to ensure accurate dosing. Administering
medications separately allows for proper absorption and can prevent complications such as clogging of the tube.

C. Adding the liquid volumes when documenting fluid intake is correct. It is essential to account for all sources of fluid intake to maintain accurate fluid balance records. Medications
administered through a gastrostomy tube contribute to the patient's overall fluid intake and must be included in the documentation.

D. Confirming that the nurse determined the amount of gastric residual is correct. This is a critical step to ensure that the patient is tolerating the feedings and to prevent complications such as
aspiration. Gastric residual volume can indicate if the patient's digestive system is processing the feeding appropriately.

E. Advising the nurse to use the plunger when giving medications is not necessary in this context. The use of a plunger can be appropriate in some situations, but the scenario does not provide enough information to suggest that the nurse had difficulty administering the medications that would require the use of a plunger. Additionally, using a plunger can increase the risk of tube
damage or patient discomfort.