A nurse is preparing to administer enteral medication to a client who has a gastrostomy tube. Which of the following actions should the nurse take first?

Flush the tube with water.

Measure stomach contents.

Elevate the head of the bed.

Return gastric content into the gastrostomy tube.

Answer and Explanation

The Correct Answer is B

A. Flushing the tube with water is necessary after checking residual stomach contents to clear the tube, but measuring stomach contents comes first to ensure the tube is clear for proper medication administration.
B. Measuring stomach contents is crucial before administering enteral medication to confirm the tube's placement and ensure medication reaches the stomach appropriately, preventing complications such as aspiration.
C. Elevating the head of the bed is important during and after enteral feeding to prevent aspiration, but it is not the first action before medication administration.
D. Returning gastric content into the gastrostomy tube may be necessary after assessing and managing residual stomach contents, but it is not the initial step in medication administration.

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Correct Answer is B

Explanation

A. Black, tarry stools are not an expected effect of subcutaneous heparin; this symptom should be reported to a healthcare provider.
B. Using a soft bristle toothbrush is recommended to minimize the risk of bleeding gums, which can occur due to heparin's anticoagulant effects.
C. Subcutaneous heparin should be injected into the fatty tissue of the abdomen or thigh, not deep into the muscle.
D. Easy bruising is a potential side effect of heparin but does not indicate effectiveness; it should be monitored and reported if excessive.

A. Ask the client to remain in a side-lying position with the affected ear down for several minutes after instillation. B. Pull the client's pinna down and back prior to instillation. C. Warm the medication to room temperature before administration. D. Press a cotton ball into the client's ear canal after instillation.

Correct Answer is C

Explanation

A. Asking the client to remain in a side-lying position comes after administering the drops to facilitate medication retention, but it's not the first action.
B. Pulling the client's pinna down and back straightens the ear canal, but this technique is used for children < 3years. For adults the pinna should be pulled upwards and outwards.
C. Warming the medication may not be necessary to prevent dizziness.
D. Placing a cotton ball in the ear canal after instillation is not necessary for otic medication administration and should not be done routinely.

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A nurse is preparing to administer enteral medication to a client who has a gastrostomy tube. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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