Before delivering a drug through an enteral tube, it is most important for the nurse to do which of the following FIRST?
Instill 5 ml of water to rinse the tube.
Check the tube placement.
Lay the client flat.
Assess the client's bowel sounds.
The Correct Answer is B
Choice A rationale
Instilling water to rinse the tube is an important step after medication administration or prior to administering incompatible medications, but it is not the initial and most crucial step before delivering any drug. Placement verification is paramount.
Choice B rationale
Scientifically, confirming tube placement is the absolute first and most critical step before administering any substance, including medication, through an enteral tube. Misplaced tubes can lead to aspiration pneumonia or inefficient drug absorption, posing significant patient safety risks.
Choice C rationale
Laying the client flat may increase the risk of aspiration, especially if the tube is misplaced or if the client has impaired gag reflex. Proper positioning, typically semi-Fowler's, is crucial for safe enteral feeding and medication administration.
Choice D rationale
Assessing bowel sounds is important for evaluating gastrointestinal motility and absorption capacity before initiating or continuing enteral feedings, but it is not the primary immediate safety check required before administering a single dose of medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["35"]
Explanation
Step 1 is to calculate the total drops to be infused. 100 mL × 15 gtt/mL = 1500 gtt.
Step 2 is to calculate the flow rate in drops per minute. 1500 gtt ÷ 30 minutes = 50 gtt/min. The final calculated answer is 50 gtt/min
Correct Answer is D
Explanation
Choice A rationale
Avoiding palpation of tender areas completely would be an incomplete assessment. While direct, forceful palpation of an acutely tender area should be approached cautiously, it is essential to gently assess the area's boundaries, consistency, and the presence of rebound tenderness or guarding to gather crucial diagnostic information.
Choice B rationale
Examining the tender area first in an abdominal assessment can cause significant pain and muscle guarding, making it difficult to assess other quadrants effectively and potentially skewing the assessment findings. This approach can also reduce patient cooperation for the remainder of the examination.
Choice C rationale
Auscultation for bowel sounds typically precedes palpation in an abdominal assessment because palpation can alter bowel motility and therefore the character of bowel sounds. While palpating the tender area last is correct, performing auscultation after palpation would introduce an artifact.
Choice D rationale
Examining the tender area last is the correct technique during an abdominal assessment. This approach minimizes patient discomfort, allows for a more thorough and accurate assessment of the non-tender areas first, and helps to establish rapport before eliciting potential pain, thereby ensuring a more reliable and complete examination.
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