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 B
Explanation
Choice A rationale
A stat medication order signifies an immediate and urgent administration of the drug, typically within 30 minutes of the order. This is for critical situations where delay could significantly impact patient outcome, requiring prompt action rather than nurse's judgment for necessity.
Choice B rationale
A PRN (pro re nata) medication order means "as needed.”. This type of order grants the nurse professional discretion to administer the medication based on their assessment of the patient's condition and the specific criteria outlined in the order, such as pain level or fever.
Choice C rationale
A scheduled medication order involves administering the drug at regularly prescribed intervals, such as every 8 hours or once daily. The timing is predetermined, and the nurse's primary role is adherence to the schedule, with less independent judgment regarding administration necessity.
Choice D rationale
A single-dose order is for a medication to be given only once at a specific time. This is often used for preoperative medications or diagnostic procedures. Like scheduled orders, the timing is set, and the nurse's judgment about the necessity of administration is not the primary factor.
Correct Answer is D
Explanation
Choice A rationale
Ankylosis refers to the stiffening and immobility of a joint due to fusion of the bones. This condition is typically caused by chronic inflammation or injury, leading to bone remodeling and eventual bridging of the joint space. It is a pathological process that restricts movement and is not a normal physiological adaptation during pregnancy.
Choice B rationale
Scoliosis is an abnormal lateral curvature of the spine, often accompanied by rotation of the vertebrae. It can be congenital, neuromuscular, or idiopathic. This spinal deformity deviates from the normal sagittal plane alignment and is not a typical physiological compensatory mechanism for the gravid uterus.
Choice C rationale
Kyphosis is an excessive outward curvature of the thoracic spine, resulting in a hunched back appearance. While some degree of thoracic kyphosis is normal, an exaggerated curve can be pathological. It does not represent the compensatory postural change seen in pregnant women, which primarily involves the lumbar region.
Choice D rationale
Lordosis is an increased inward curvature of the lumbar spine. During pregnancy, as the uterus enlarges anteriorly, the woman's center of gravity shifts forward. To maintain balance and prevent falling, the abdominal muscles stretch and the lumbar spine accentuates its inward curve, which is known as lordosis, a physiological adaptation.
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