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 D
Explanation
Choice A rationale
Asking the patient to turn their head side-to-side against resistance assesses the accessory nerve (cranial nerve XI), which innervates the sternocleidomastoid and trapezius muscles. This action tests muscle strength and integrity of the nerve pathways responsible for head and shoulder movement.
Choice B rationale
Asking the patient to stick out the tongue and move it side-to-side from midline assesses the hypoglossal nerve (cranial nerve XII). This nerve is responsible for the motor control of the intrinsic and extrinsic muscles of the tongue, crucial for speech articulation and swallowing.
Choice C rationale
Asking the patient to read the smallest set of letters on a Snellen eye chart assesses visual acuity, primarily testing the optic nerve (cranial nerve II) and the visual pathways. This evaluates the patient's ability to discern details at a distance.
Choice D rationale
Asking the patient to identify the smell of vanilla and orange peel directly assesses the olfactory nerve (cranial nerve I). This nerve is responsible for the sense of smell, and presenting distinct, non-irritating odors allows for the evaluation of its function and patency.
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.
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