A client has a nasogastric tube and the medication tablets will need to be crushed. After verifying in the drug guide which tablets can be crushed, the nurse crushes each medication individually, mixes each in 20 mL of fluid and administers them one at a time down the nasogastric tube Which phase of the nursing process does this represent.

Planning

Diagnosis

Evaluation

Implementation

Assessment

Answer and Explanation

The Correct Answer is D

A) Planning: The planning phase involves setting goals and determining the actions needed to achieve those goals. While the nurse may have planned to administer the medications through the nasogastric tube, the specific actions of crushing the tablets, mixing them with fluid, and administering them fall under a different phase. Therefore, planning is not the correct phase for the actions described.

B) Diagnosis: The diagnosis phase is when the nurse identifies and formulates nursing diagnoses based on data collected about the patient’s health status. The actions of preparing and administering medication do not fall under this phase, as diagnosis pertains to assessing health problems or needs.

C) Evaluation: Evaluation is the phase where the nurse assesses whether the goals or outcomes of the care plan have been met. The nurse would evaluate the effectiveness of the medication administration after it has been done, but the actual action of giving the medication is part of implementation, not evaluation.

D) Implementation: Implementation is the phase where the nurse carries out the planned interventions, including administering medications. In this case, the nurse is taking specific steps to prepare and administer the crushed tablets down the nasogastric tube, which is a direct action related to the care plan. This phase involves performing the tasks necessary to carry out the interventions that were decided during the
planning phase.

E) Assessment: Assessment involves collecting data about the client’s health status, such as physical examination, history, and vital signs. The actions taken to crush and administer medications are not part of the assessment phase, which focuses on gathering information, not delivering care.

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Correct Answer is C

Explanation

A) The stomach acid has a lower pH level which results in increased absorption: While it is true that neonates have a lower gastric pH, which could affect the absorption of certain medications, this factor does not directly increase the risk for drug toxicity. Lower pH may increase absorption for some drugs, but it is not as critical in neonates as the immaturity of other organs, such as the liver and kidneys, which are responsible for drug metabolism and excretion.

B) The glomerular filtration rate (GFR) is increased causing rapid excretion: In neonates, the glomerular filtration rate (GFR) is actually decreased, not increased. This leads to slower excretion of medications, which can increase the risk for drug toxicity, especially for drugs that rely on renal elimination. This decreased renal function can result in accumulation of the drug in the bloodstream, potentially leading to toxicity.

C) The liver enzyme system responsible for drug metabolism is not fully developed: The liver enzyme system in neonates is immature, which significantly impacts the metabolism of drugs. Enzymatic activity is critical for breaking down medications to their active or inactive forms. Due to the underdeveloped liver function, drugs may not be metabolized properly, leading to a longer half-life and an increased risk for drug toxicity. This is a key factor in the increased risk of toxicity in neonatal clients.

D) The albumin levels are elevated due to rapid growth and protein binding is enhanced: Neonates typically have lower albumin levels, not elevated levels. Albumin is crucial for binding medications, and lower levels in neonates can result in more free (unbound) drug circulating in the bloodstream, which can increase the risk of drug toxicity. Elevated albumin would theoretically reduce this risk, but this is not typically the case in neonates.

A. 50 B. 100 C. 25 D. 75

Correct Answer is C

Explanation

Here’s the step-by-step process:

After the first half-life (1 half-life), 50% of the initial drug is left.

200 mg → 100 mg (half is eliminated, 100 mg remains).

After the second half-life (2 half-lives), 50% of the remaining drug is eliminated again.

100 mg → 50 mg (half of 100 mg is eliminated, 50 mg remains).

After the third half-life (3 half-lives), 50% of the remaining drug is eliminated again.

50 mg → 25 mg (half of 50 mg is eliminated, 25 mg remains).

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Naxlex Comprehensive Predictor Exams

The nurse is administering a prescribed medication to neonatal client. Which factor is most likely to increase the risk for drug toxicity in this client?

Correct Answer is C

Explanation

The client receives one dose of 200 mg of a medication. How much drug is in the body at 3 half-lives?

Correct Answer is C

Explanation

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