The charge nurse observes a new nurse demonstrate the administration of two different liquid medications through a gastrostomy tube used for continuous feedings Which action(s) should the charge nurse take? (Select all that apply)
Advise the nurse to use the plunger when giving medications.
Encourage the nurse to flush the tube with more water.
Confirm that the nurse determined the amount of gastric residual.
Instruct the nurse to administer each medication separately.
Add the liquid volumes when documenting fluid intake.
Correct Answer : B,C,D,E
A. Advising the nurse to use the plunger when giving medications is not recommended as it can create too much pressure and potentially damage the gastrostomy tube or cause discomfort to the patient. It's important to allow the medication to flow by gravity to prevent these issues.
B. Encouraging the nurse to flush the tube with more water is correct because it helps to ensure that the medication is cleared from the tube and reduces the risk of clogging. Flushing with water also helps to maintain hydration for the patient.
C. Confirming that the nurse determined the amount of gastric residual is correct because it is essential to check for any undigested food or medication in the stomach before administering more. This helps to prevent aspiration and other complications.
D. Instructing the nurse to administer each medication separately is correct. This practice
prevents drug interactions within the tube and ensures that each medication is given correctly and has the intended effect.
E. Adding the liquid volumes when documenting fluid intake is correct because all fluids
administered, including medications, should be accounted for in the patient's fluid balance. This is crucial for monitoring and managing the patient's hydration status and overall health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
A. While managing pain is important, the client did not report significant pain, making it a lower priority in this scenario.
B. Quitting smoking is crucial for the client's respiratory health, especially given the history of smoking and current respiratory symptoms.
C. There is no indication that the client is at risk of skin breakdown; thus, it is not a priority in the immediate discharge plan.
D. Maintaining an oxygen saturation of 96% without supplemental oxygen is a direct indicator of improved respiratory function and a key goal for discharge.
E. Being afebrile for 24 hours would indicate that the infection is under control, which is a primary concern for discharge after presenting with flu-like symptoms.
Correct Answer is A
Explanation
A. Observing the insertion site of the suprapubic catheter is crucial to assess for signs of infection, such as redness, swelling, or drainage. Any abnormalities at the insertion site should be reported promptly for further evaluation and intervention.
B. Palpating the flank area may not be directly related to the care of the suprapubic catheter unless there are specific concerns or symptoms related to the renal system that warrant assessment of the kidneys.
C. While measuring abdominal girth can provide information about abdominal distention or fluid accumulation, it may not directly address the care needs related to the suprapubic catheter unless there are specific concerns related to catheter function or drainage.
D. Assessing the perineal area may be relevant for clients with other types of urinary catheters (e.g., indwelling urethral catheters), but for clients with a suprapubic catheter, the focus is on the site of catheter insertion in the lower abdomen.
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