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.

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.

Assessment: Patient had 2 semi-formed bowel movements 1 hour after administration of the medication

Choice A Reason:

Assessment: Patient denies vomiting

This choice is not directly related to the effectiveness of Kayexalate. Vomiting can be a symptom of hyperkalemia, but the absence of vomiting does not indicate that the medication is working. Kayexalate works by binding potassium in the intestines and removing it through the stool, so the presence of bowel movements is a more direct indicator of its effectiveness.

Choice B Reason:

ECG: Flattening of QRS complex angle

Flattening of the QRS complex angle is not a typical ECG change associated with hyperkalemia or its treatment. Hyperkalemia typically causes widening of the QRS complex, and effective treatment would normalize this. Therefore, this choice is not correct.

Choice C Reason:

ECG: Widening of the QRS complex

Widening of the QRS complex is a sign of hyperkalemia, not its resolution. If the medication is effective, the QRS complex should return to a normal width. Therefore, this choice is not correct.

Choice D Reason:

Assessment: Patient consumed 60% of meal

While nutritional intake is important, it is not a direct indicator of the effectiveness of Kayexalate. The medication’s effectiveness is better assessed by changes in potassium levels and related symptoms, not by meal consumption.

Choice E Reason:

Assessment: Patient denies nausea

Similar to vomiting, nausea can be a symptom of hyperkalemia, but the absence of nausea does not indicate that the medication is working. The effectiveness of Kayexalate is better assessed by the presence of bowel movements and changes in potassium levels.

Choice F Reason:

Assessment: Patient had 2 semi-formed bowel movements 1 hour after administration of the medication

This is the correct answer. Kayexalate works by binding potassium in the intestines and removing it through the stool. The presence of bowel movements indicates that the medication is working to remove potassium from the body. This is a direct and relevant assessment finding.

Choice G Reason:

ECG: Shortening of P wave duration

Shortening of the P wave duration is not a typical ECG change associated with hyperkalemia or its treatment. Therefore, this choice is not correct.

Choice H Reason:

Assessment: Patient denies pain

Pain is not a typical symptom of hyperkalemia, and its absence does not indicate that the medication is working. Therefore, this choice is not correct.

Choice I Reason:

ECG: Reduction of T wave amplitude

Reduction of T wave amplitude can be a sign of hypokalemia, not hyperkalemia. Effective treatment of hyperkalemia would normalize the T wave amplitude, not reduce it. Therefore, this choice is not correct.