When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?

Contact the pharmacy and confirm that the dosage is safe to administer.

Ask another nurse to verify that the dosage is appropriate for the client

Inform the charge nurse and administer the dose of the medication the provider prescribed.

Contact the provider to question the dosage.

Answer and Explanation

The Correct Answer is D

A.   Contacting the pharmacy might be a good step in some cases, but if the nurse has identified a dosage that is three times higher than usual, it's crucial to address this directly with the prescribing provider first.
B.   Asking another nurse to verify is a reasonable step, but ultimately, it's the responsibility of the nurse who identifies the discrepancy to take action.
C.   Informing the charge nurse and administering the dose without questioning the provider's order could potentially put the client at risk if the dosage is indeed too high.
D.   Contacting the provider to question the dosage is the most appropriate immediate action. It's crucial to seek clarification from the provider regarding the unusually high dosage to ensure the safety and well-being of the client. This step ensures that the client receives the correct and safe medication dosage.

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Correct Answer is C

Explanation

A. Observing the client's respiratory status is also important, but it is an ongoing assessment rather than an immediate action.

B. Monitoring intake and output every 8 hours is important for overall fluid balance, but it is not the top priority in this situation.

C. This is crucial to prevent aspiration, which can occur if the feeding formula enters the lungs, leading to pneumonia or other serious complications. Elevating the head of the bed helps keep the esophagus above the stomach, reducing the risk of aspiration.

D. Checking residual volume every 4 to 6 hours is a part of enteral feeding care, but it is not the top priority. Monitoring respiratory status takes precedence due to the potential risk of aspiration.

A. To remove gastric acid that might cause dyspepsia B. To confirm the placement of the NG tube C. To identify delayed gastric emptying D. To determine the client's electrolyte balance

Correct Answer is C

Explanation

A. Measuring the gastric residual is a common practice before administering enteral feedings. It helps to assess if the client's stomach is emptying properly and if there is any buildup of undigested formula. This is important in identifying delayed gastric emptying, which can lead to complications if not addressed.
B. To remove gastric acid that might cause dyspepsia is not the primary purpose of measuring gastric residual. The main concern is to assess the rate of stomach emptying.
C. To confirm the placement of the NG tube is typically done using other methods, such as pH testing or an X-ray. While aspirating stomach contents through the tube can help confirm placement, it is not the primary purpose of measuring gastric residual.
D. To determine the client's electrolyte balance is not related to the purpose of measuring gastric residual. Electrolyte balance is typically assessed through blood tests and clinical signs and symptoms.

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When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is C

Explanation

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

Correct Answer is C

Explanation

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