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 D
Explanation
A. Client's healthcare power of attorney - This is important legal information but not the most immediate concern for the healthcare provider.
B. Currently prescribed medications - While important, this information does not represent an immediate change in the client's condition.
C. Fall at home as reason for admission - This is background information and, although important, is not the most pressing issue if the client's condition is worsening.
D. Increasing confusion of the client - The increasing confusion could indicate a change in the client's baseline mental status, which could be a sign of a serious condition such as a subdural hematoma or infection and should be communicated immediately.
Correct Answer is C
Explanation
A. Increasing the intake of dark green leafy vegetables while taking warfarin can affect INR levels due to their high vitamin K content, potentially increasing the risk of bleeding.
B. Eating two servings of raw dark green leafy vegetables daily and continuing for 30 days after warfarin therapy is completed is not recommended as it may affect INR levels.
C. Eating approximately the same amount of leafy green vegetables daily helps maintain consistent vitamin K intake, which is important for keeping INR levels stable while on warfarin therapy.
D. Avoiding all foods containing vitamin K is not necessary and may lead to nutritional
deficiencies; instead, it's important to consume a consistent amount of vitamin K-containing foods.
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