The nurse is preparing to administer medication using a client’s nasogastric tube. Which actions should the nurse take before administering the medication? Select all that apply.

Aspirate the stomach contents.

Check the residual volume.

Remove the tube and place it in the other nostril.

Test the stomach contents for a pH indicating acidity.

Turn off the suction to the nasogastric tube.

Answer and Explanation

Correct Answer : A,B,D,E

Choice A Reason:

Aspirating the stomach contents is essential to ensure the nasogastric tube is correctly positioned in the stomach. This step helps verify that the tube has not migrated and is safe for medication administration. If the aspirate is not obtained, further steps should be taken to confirm the tube’s placement.

Choice B Reason:

Checking the residual volume is important to assess the stomach’s contents and ensure that the patient is tolerating the feedings or medications. High residual volumes may indicate delayed gastric emptying or other gastrointestinal issues. This information helps guide the timing and amount of medication administration.

Choice C Reason:

Removing the tube and placing it in the other nostril is not a standard practice before administering medication. This action is unnecessary and could cause discomfort or complications for the patient. The focus should be on verifying the tube’s placement and ensuring it is functioning correctly.

Choice D Reason:

Testing the stomach contents for a pH indicating acidity is a reliable method to confirm the nasogastric tube’s placement. Gastric contents typically have a pH of 1 to 5, indicating the tube is in the stomach. This step helps ensure the safe administration of medications.

Choice E Reason:

Turning off the suction to the nasogastric tube is necessary before administering medications. Suction can interfere with the absorption of the medication and may cause the medication to be removed from the stomach before it has a chance to take effect. Therefore, it is important to turn off the suction temporarily during medication administration.

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Correct Answer is ["A","D","E"]

Explanation

Choice A Reason:

Cool, clammy skin is a common symptom in patients with atrial fibrillation, especially when the heart rate is very high. This symptom occurs due to decreased cardiac output, which leads to poor perfusion of the skin. When the heart is beating too fast, it doesn’t have enough time to fill properly, resulting in less blood being pumped out to the body. This can cause the skin to feel cool and clammy as the body tries to compensate for the reduced blood flow.

Choice B Reason:

Respiratory rate of 20 is within the normal range for adults, which is typically 12-20 breaths per minute. While it is important to monitor respiratory rate in patients with atrial fibrillation, a rate of 20 does not indicate any immediate distress or abnormality. Therefore, this choice is not particularly relevant to the assessment of a patient with a heart rate of 143 beats/min due to atrial fibrillation.

Choice C Reason:

Flushing of the skin is not a typical symptom associated with atrial fibrillation. Flushing can occur due to various reasons such as fever, anxiety, or certain medications, but it is not directly linked to the high heart rate or the irregular rhythm seen in atrial fibrillation. Therefore, this choice is not applicable in this context.

Choice D Reason:

Hypotension (low blood pressure) is a significant concern in patients with atrial fibrillation, especially when the heart rate is very high. The rapid heart rate can lead to decreased cardiac output, as the heart does not have enough time to fill properly between beats. This can result in lower blood pressure, which can cause symptoms such as dizziness, fainting, and fatigue. Monitoring blood pressure is crucial in managing patients with atrial fibrillation to prevent complications.

Choice E Reason:

Chest discomfort is a common symptom in patients with atrial fibrillation, particularly when the heart rate is very high. The irregular and rapid heart rate can cause the heart to work harder, leading to increased oxygen demand and potentially reduced oxygen supply to the heart muscle. This imbalance can result in chest pain or discomfort, which is a warning sign that the heart is under stress. It is important to assess and address chest discomfort promptly to prevent further cardiac complications.

A. QT interval B. Heart rate C. Respiratory rate D. Heart rhythm E. Urine output

Correct Answer is ["A","B","C","D","E"]

Explanation

Title: Choice A Reason:

Monitoring the QT interval is crucial when administering amiodarone because this drug can prolong the QT interval, increasing the risk of torsades de pointes, a potentially life-threatening type of ventricular tachycardia. Regular monitoring helps in early detection and management of this adverse effect, ensuring patient safety.

Title: Choice B Reason:

Heart rate monitoring is essential as amiodarone can cause bradycardia (slow heart rate). Continuous monitoring allows the nurse to detect any significant changes in heart rate and take appropriate actions, such as adjusting the medication dosage or providing interventions to manage bradycardia.

Title: Choice C Reason:

Respiratory rate monitoring is necessary because amiodarone can cause pulmonary toxicity, including interstitial pneumonitis and acute respiratory distress syndrome (ARDS). By keeping track of the respiratory rate, the nurse can identify early signs of respiratory complications and intervene promptly

Title: Choice D Reason:

Heart rhythm monitoring is vital since amiodarone is used to treat arrhythmias. Continuous electrocardiogram (ECG) monitoring helps in assessing the effectiveness of the drug in controlling arrhythmias and detecting any new or worsening arrhythmias that may require immediate attention.

Title: Choice E Reason:

Monitoring urine output is important because amiodarone can affect renal function, especially in patients with pre-existing kidney conditions. Keeping track of urine output helps in assessing renal function and ensuring that the drug is not causing nephrotoxicity

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The nurse is preparing to administer medication using a client’s nasogastric tube. Which actions should the nurse take before administering the medication? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a heart rate of 143 beats/min with atrial fibrillation. Which assessment data will the nurse anticipate? Select all that apply:

Correct Answer is ["A","D","E"]

Explanation

The nurse administers amiodarone to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? (Select all that apply)

Correct Answer is ["A","B","C","D","E"]

Explanation

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