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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
Choice A rationale
The ventrogluteal muscle is a preferred site for Z-track injections due to its thick musculature, which minimizes the risk of hitting nerves or blood vessels. Its anatomical location provides a deep, safe space for medication deposition, allowing for effective sealing of the drug within the muscle tissue, preventing leakage and irritation to subcutaneous tissues.
Choice B rationale
The deltoid muscle is generally not preferred for Z-track injections because its smaller muscle mass and proximity to the radial nerve and brachial artery increase the risk of neurovascular injury. While used for some intramuscular injections, the Z-track technique benefits from larger muscle groups to effectively seal the medication.
Choice C rationale
The dorsogluteal muscle, though historically used, is considered less ideal than the ventrogluteal site for Z-track injections due to a higher risk of sciatic nerve injury and penetration of major blood vessels. However, its large muscle mass can still accommodate Z-track injections when alternative sites are contraindicated, if proper landmarks are meticulously observed.
Choice D rationale
The abdomen, 2 inches from the umbilicus, is primarily used for subcutaneous injections, not intramuscular Z-track injections. This area lacks the deep muscle tissue necessary to effectively deposit and seal medication using the Z-track technique, and attempting intramuscular injection here poses a high risk of hitting vital organs.
Choice E rationale
The posterior thigh, specifically the rectus femoris or vastus lateralis, can be used for intramuscular injections, but it is not a primary preferred site for the Z-track technique in adults due to varying muscle thickness and increased potential for discomfort. The ventrogluteal site generally offers a larger and safer muscle mass.
Correct Answer is A
Explanation
Choice A rationale
A bruit is an abnormal vascular sound, typically a loud, whooshing, or blowing murmur, caused by turbulent blood flow through a narrowed or partially obstructed artery. It is best auscultated with the bell of the stethoscope, which is more effective at detecting low-pitched sounds due to its larger surface area and ability to transmit vibrations from a broader area of contact. The turbulence creates vibratory patterns indicative of compromised blood flow.
Choice B rationale
A high-pitched tinkling sound is not characteristic of a bruit and is more commonly associated with bowel sounds in cases of intestinal obstruction, indicating fluid and gas movement within the bowel. The diaphragm of the stethoscope is indeed used for high-pitched sounds, but this specific sound quality does not align with the pathophysiology of a vascular bruit.
Choice C rationale
A soft, trickling, pulsatile sound does not describe a bruit. While pulsatile, the "soft, trickling" quality suggests a very low-flow state or venous hum rather than the turbulent arterial flow responsible for a true bruit. The bell is appropriate for low-pitched sounds, but the character of the sound is inconsistent with a bruit.
Choice D rationale
A low gurgling sound is generally associated with gastrointestinal motility, such as normal bowel sounds, and is not indicative of a vascular bruit. While low-pitched sounds can be detected with the bell, the diaphragm is used for higher-pitched sounds, and the "gurgling" description is inappropriate for arterial turbulence.
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