The nurse is preparing to administer medication using a client’s nasogastric tube. Which actions should the nurse take before administering the medication? Select all that apply.

Aspirate the stomach contents.

Check the residual volume.

Remove the tube and place it in the other nostril.

Test the stomach contents for a pH indicating acidity.

Turn off the suction to the nasogastric tube.

Answer and Explanation

Correct Answer : A,B,D,E

Choice A Reason:

Aspirating the stomach contents is essential to ensure the nasogastric tube is correctly positioned in the stomach. This step helps verify that the tube has not migrated and is safe for medication administration. If the aspirate is not obtained, further steps should be taken to confirm the tube’s placement.

Choice B Reason:

Checking the residual volume is important to assess the stomach’s contents and ensure that the patient is tolerating the feedings or medications. High residual volumes may indicate delayed gastric emptying or other gastrointestinal issues. This information helps guide the timing and amount of medication administration.

Choice C Reason:

Removing the tube and placing it in the other nostril is not a standard practice before administering medication. This action is unnecessary and could cause discomfort or complications for the patient. The focus should be on verifying the tube’s placement and ensuring it is functioning correctly.

Choice D Reason:

Testing the stomach contents for a pH indicating acidity is a reliable method to confirm the nasogastric tube’s placement. Gastric contents typically have a pH of 1 to 5, indicating the tube is in the stomach. This step helps ensure the safe administration of medications.

Choice E Reason:

Turning off the suction to the nasogastric tube is necessary before administering medications. Suction can interfere with the absorption of the medication and may cause the medication to be removed from the stomach before it has a chance to take effect. Therefore, it is important to turn off the suction temporarily during medication administration.

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

Explanation

Choice A Reason: High-flow nasal cannula

The high-flow nasal cannula (HFNC) is designed to deliver oxygen at flow rates much higher than 5 liters per minute, typically ranging from 20 to 60 liters per minute. It is used for patients requiring high levels of oxygen and positive airway pressure. Therefore, it is not appropriate for a flow rate of 5 liters per minute.

Choice B Reason: Simple face mask

The simple face mask is suitable for delivering oxygen at flow rates between 6 to 10 liters per minute. However, it can also be used at a flow rate of 5 liters per minute, providing an FiO2 (fraction of inspired oxygen) of approximately 40-60%. This makes it an appropriate choice for the given requirement.

Choice C Reason: Nasal cannula

The nasal cannula is a low-flow oxygen delivery device that can deliver oxygen at flow rates from 1 to 6 liters per minute. At 5 liters per minute, it provides an FiO2 of approximately 40%. It is comfortable for patients and is commonly used for those who need a moderate amount of supplemental oxygen.

Choice D Reason: Non-rebreather mask

The non-rebreather mask is designed to deliver high concentrations of oxygen, typically at flow rates of 10 to 15 liters per minute. It is used in situations where patients need a high FiO2, close to 100%. Therefore, it is not suitable for a flow rate of 5 liters per minute.

Choice E Reason: Venturi mask

The Venturi mask is used to deliver precise oxygen concentrations, typically ranging from 24% to 60% FiO2. It is suitable for patients who require controlled oxygen therapy. While it can be adjusted to deliver oxygen at a flow rate of 5 liters per minute, it is generally used for more specific FiO2 requirements.

A. QT interval B. Heart rate C. Respiratory rate D. Heart rhythm E. Urine output

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

Explanation

Choice A Reason:

Monitoring the QT interval is crucial when administering amiodarone because this drug can prolong the QT interval, increasing the risk of torsades de pointes, a potentially life-threatening form of ventricular tachycardia. The QT interval represents the time it takes for the heart’s ventricles to depolarize and repolarize, and prolongation can lead to arrhythmias. Regular monitoring helps in early detection and prevention of such adverse effects.

Choice B Reason:

Heart rate monitoring is essential when administering amiodarone because the drug can cause bradycardia (a slower than normal heart rate). Amiodarone affects the electrical conduction system of the heart, which can lead to significant changes in heart rate. Monitoring the heart rate ensures that any bradycardia is detected early and managed appropriately to prevent complications such as hypotension or heart failure.

Choice C Reason:

While respiratory rate monitoring is important in general patient care, it is not specifically necessary for monitoring the effects of amiodarone. Amiodarone primarily affects the heart’s electrical activity and has less direct impact on respiratory function. However, in cases of severe adverse reactions, such as pulmonary toxicity, respiratory monitoring may become relevant.

Choice D Reason:

Monitoring heart rhythm is vital when administering amiodarone because the drug is used to treat arrhythmias and can also cause new arrhythmias or exacerbate existing ones. Continuous ECG monitoring helps in detecting any abnormal heart rhythms early, allowing for timely intervention. This is particularly important in patients with a history of arrhythmias or those receiving high doses of amiodarone.

Choice E Reason:

Urine output monitoring is not specifically necessary for patients receiving amiodarone. While maintaining adequate urine output is important for overall patient health, amiodarone does not typically affect renal function directly. Therefore, urine output monitoring is not a primary concern when administering this medication.

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The nurse is preparing to administer medication using a client’s nasogastric tube. Which actions should the nurse take before administering the medication? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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

Explanation

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