A nurse has just administered medication via an orogastric tube. What is the priority nursing action following administration?

Check tube placement.

Retape the tube.

Flush the tube.

Remove the tube.

Answer and Explanation

The Correct Answer is C

A. Check tube placement: Tube placement should be verified before administering any medication to ensure that the tube is in the stomach and not the respiratory tract. Checking placement afterward does not prevent complications from incorrect placement.

B. Retape the tube: Retaping may be necessary if the tube is loose, but it is not the priority action after giving medication. The immediate concern is maintaining tube patency and preventing clogging.

C. Flush the tube: Flushing the orogastric tube with sterile or tap water after medication administration is the priority. It ensures that the full dose of the drug enters the stomach, prevents drug interactions or residue buildup in the tubing, and maintains patency.

D. Remove the tube: The orogastric tube should not be removed unless specifically ordered or if there is a clinical reason. Removal immediately after medication administration would prevent ongoing nutritional or medication use and is not a standard practice.

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Correct Answer is D

Explanation

A. Palpate the breasts: Palpation is performed after inspection to assess for lumps, tenderness, or abnormalities. Starting with palpation may miss subtle visual changes and could cause discomfort before completing the visual assessment.

B. Palpate the axillary area: The axillary area is palpated after breast palpation to check for lymph node enlargement or tenderness. This step helps identify possible spread of infection or malignancy but is not the first part of the exam.

C. Compress the nipple for a discharge: Nipple compression is performed later in the examination to check for abnormal discharge. Doing it first could obscure or alter inspection findings by stimulating tissue changes.

D. Inspect the breasts: Inspection is always the first step. The nurse observes breast size, symmetry, contour, skin texture, color, and the condition of the nipples. This provides baseline information and guides where to focus palpation during the physical exam.

A. "I should avoid applying ice or heat to my genital area." B. "I need to wash my hands after touching any of the lesions." C. "I can try lukewarm sitz baths to help ease the discomfort." D. "I need to abstain from intercourse primarily when the lesions are present."

Correct Answer is A

Explanation

A. "I should avoid applying ice or heat to my genital area.": Applying ice packs wrapped in a clean cloth can help relieve pain and swelling associated with genital herpes. Heat, however, should be avoided as it may increase irritation.

B. "I need to wash my hands after touching any of the lesions.": Proper hand hygiene is essential to prevent autoinoculation or transmission of the herpes virus to other body parts or individuals. Washing hands thoroughly after contact with lesions helps minimize the risk of spreading the infection.

C. "I can try lukewarm sitz baths to help ease the discomfort.": Sitz baths using lukewarm water can soothe irritated tissues, promote cleanliness, and provide comfort during outbreaks. This measure helps relieve pain without aggravating the lesions.

D. "I need to abstain from intercourse primarily when the lesions are present.": Abstaining from sexual contact during active outbreaks reduces the risk of transmitting the herpes virus. However, even when lesions are absent, the virus can still shed asymptomatically, so barrier protection should always be recommended.

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A nurse has just administered medication via an orogastric tube. What is the priority nursing action following administration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a clinical breast examination, which would the nurse do first?

Correct Answer is D

Explanation

A nurse is teaching a woman with genital herpes how to care for the lesions. Which statement by the client indicates a need for additional teaching?

Correct Answer is A

Explanation

The nurse contacts a child life specialist (CLS) to work with children on a pediatric ward. What is the primary goal of the CLS?

During a clinical breast examination, the nurse palpates a well-defined, firm, mobile lump in a 60-year-old woman's left breast. The nurse notifies the primary care provider. What would the nurse anticipate the care provider to prescribe next?

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