A nurse administering medications through a tube must remember which of the following?
Turn the patient to the right side once medications have been administered.
Leave patient in high-Fowler's position for 30 minutes after administering medication.
Flush the tube with 10-15 mL of water after each medication.
Hold the medication if 50 ml of residual is obtained.
The Correct Answer is B
Choice A rationale
Turning the patient to the right side immediately after medication administration via a tube is generally not recommended as it may promote rapid gastric emptying which can potentially lead to dumping syndrome or alter drug absorption by moving the medication out of the stomach too quickly.
Choice B rationale
Leaving the patient in a high-Fowler's position for 30 minutes after administering medications through a tube helps prevent aspiration by utilizing gravity to keep the medication in the stomach. This position also aids in proper digestion and absorption by maintaining gastrointestinal motility and reducing reflux.
Choice C rationale
Flushing the tube with 10-15 mL of water after each medication is generally insufficient to clear the tube effectively and prevent clogging, especially with viscous medications. A standard flush volume of 30-60 mL is typically recommended to ensure complete medication delivery and tube patency.
Choice D rationale
Holding medication if 50 mL of residual is obtained is not a universal standard. The acceptable residual volume varies based on institutional policy, patient condition, and the type of feeding. Often, a residual volume of 200-250 mL or more is the threshold for holding medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The clavicle is a superficial bone forming part of the shoulder girdle and does not serve as a primary site for eliciting deep tendon reflexes. Deep tendon reflexes involve muscle stretch and nerve innervation.
Choice B rationale
The scapula is a large, triangular bone located on the posterior aspect of the rib cage and is not an anatomical landmark used for assessing deep tendon reflexes. Reflexes are elicited from tendons connected to muscles.
Choice C rationale
The patella, or kneecap, is the anatomical landmark where the patellar tendon connects to the quadriceps muscle. Tapping this tendon elicits the patellar reflex, a commonly assessed deep tendon reflex indicating spinal nerve integrity.
Choice D rationale
The sternum, or breastbone, is a flat bone located in the center of the chest and is not associated with the elicitation of deep tendon reflexes. Deep tendon reflexes are assessed at specific musculotendinous junctions.
Correct Answer is A
Explanation
Choice A rationale
Orientation to person, place, and time is a fundamental component of cognitive assessment, indicating intact neurological function. Knowing one's full name demonstrates personal orientation. Recognizing the hospital and its location signifies place orientation. Providing the correct month and year, even without the exact day, suggests a reasonable grasp of temporal orientation, reflecting adequate higher cortical processing.
Choice B rationale
The inability to state one's location and an incorrect year indicate significant deficits in both place and time orientation. This suggests impaired cognitive function, potentially due to delirium, dementia, or other neurological issues affecting memory and executive functions. Such a response would warrant further comprehensive cognitive evaluation.
Choice C rationale
While knowing one's name indicates personal orientation, confusion about the date points to a deficit in time orientation. This partial disorientation suggests some level of cognitive impairment, necessitating further assessment to determine the underlying cause and extent of the confusion.
Choice D rationale
Hesitation regarding location and complete inability to state the date demonstrate significant disorientation to both place and time. This pattern of response is indicative of impaired cognitive function and necessitates a thorough neurological and cognitive workup to identify potential etiologies.
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