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 A
Explanation
Choice A rationale
The posterior tibial pulse is located in the groove between the medial malleolus (inner ankle bone) and the Achilles tendon. Palpating this pulse requires a gentle but firm touch to identify the arterial pulsations. It is a common site for assessing peripheral circulation and is essential for evaluating lower extremity perfusion.
Choice B rationale
The inguinal area is the anatomical region of the groin, where the femoral pulse is located. The femoral pulse is palpable just below the inguinal ligament, midway between the anterior superior iliac spine and the pubic symphysis. This is a central pulse site, distinct from the posterior tibial pulse.
Choice C rationale
The top of the foot is where the dorsalis pedis pulse is located. This pulse is found lateral to the extensor hallucis longus tendon, over the metatarsal bones. It is another important site for assessing lower extremity perfusion but is different from the posterior tibial pulse.
Choice D rationale
Behind the knee is the location for palpating the popliteal pulse. This pulse is more difficult to assess due to its deep location within the popliteal fossa. It requires the patient's knee to be slightly flexed to relax the muscles and facilitate palpation.
Correct Answer is C
Explanation
Choice A rationale
Pulling the lobe up and back is the correct technique for administering ear drops to adults and children older than three years of age. This maneuver straightens the ear canal in older individuals due to the anatomical development and orientation of the Eustachian tube and external auditory meatus.
Choice B rationale
Instructing parents to hold the child upright for 10 minutes is an appropriate post-administration instruction to facilitate medication absorption and prevent spillage. However, this action is not part of the physical technique for correctly preparing the ear canal for drop instillation.
Choice C rationale
For children under 3 years old, the external auditory canal is straighter and angled differently than in adults. Pulling the pinna down and back straightens this shorter, more upwardly curved canal, allowing the medication to flow more effectively and reach the tympanic membrane for optimal absorption.
Choice D rationale
Massaging the tragus after instillation helps to distribute the medication throughout the ear canal and facilitate its passage deeper. However, massaging the tragus before administering the drops does not contribute to straightening the ear canal and is not a preparatory step for instillation.
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