A nurse is administering a liquid medication to a client who has an NG tube set to intermittent suction. Identify the sequence of steps the nurse should take when administering the medication. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) (ORDERED RESPONSE)
Check the client's gastric residual.
Verify the tube placement.
Pour the medication into the syringe and allow it to flow by gravity.
Clamp the NG tube for 20 to 30 min.
The Correct Answer is ["B","A","C","D"]
A. Check the client's gastric residual: After confirming tube placement, gastric residual is assessed to evaluate delayed gastric emptying, which could increase the risk of aspiration. This is done before administering medications or feedings.
B. Verify the tube placement: Tube placement is verified first to ensure the medication is delivered into the stomach and not the lungs. This prevents aspiration and other complications associated with incorrect tube placement.
C. Pour the medication into the syringe and allow it to flow by gravity: Once placement is confirmed and residual checked, the medication is administered via gravity through the syringe to minimize pressure on the NG tube and promote safe delivery.
D. Clamp the NG tube for 20 to 30 min: After administering the medication, the NG tube is clamped to allow for medication absorption before suction is resumed. Immediate suctioning would remove the medication before it can take effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}
Explanation
Target 1: Paralytic ileus
- The client is 6 hours postoperative with hypoactive bowel sounds and no mention of flatus or stool. The use of IV opioids (morphine) increases the risk for reduced gastrointestinal motility. Paralytic ileus is common after abdominal surgery and with opioid use.
Target 2: Atelectasis
- The client has shallow bilateral breath sounds postoperatively, which indicates a risk for atelectasis, a common complication due to decreased mobility, pain limiting deep breathing, and effects of anesthesia.
Rationale for Incorrect Choices:
- Urinary tract infection: The client voided 350 mL of clear yellow urine after catheter removal with no signs of infection.
- Delayed wound healing: No signs of infection or poor wound healing; the dressing is dry and intact.
- Deep vein thrombosis: Though a risk postoperatively, the client is wearing SCDs and has even pedal pulses with no edema, lowering immediate concern.
Correct Answer is C
Explanation
A. "The lower end of the sling goes below the client's calves." The lower end of the sling should support the thighs and buttocks but typically does not extend below the calves. Positioning the sling incorrectly can cause discomfort or injury during the lift.
B. "The sides of the sling are for the client to hold on to." While some slings have loops for the caregiver to grasp, clients usually do not hold onto the sling sides during the lift, as this could interfere with safe handling and stability.
C. "This type of device is useful for a client who cannot assist." Mechanical lifts are specifically designed to safely transfer clients who have little or no ability to assist with moving. This reduces injury risk for both client and caregiver and ensures safe mobility.
D. "The device requires the client to use upper body strength." Mechanical lifts minimize the need for client effort, especially upper body strength. They are intended for clients unable to bear weight or assist, so reliance on client strength contradicts the device’s purpose.
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