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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. While the refusal to eat is concerning, it does not pose an immediate risk to the client's safety.
B. The situation involving the 18-year-old client could escalate quickly and poses an immediate risk to the client's and others' safety, requiring prompt intervention.
C. Pacing may indicate agitation or anxiety; however, it does not require immediate intervention unless it escalates.
D. Refusal to participate in group therapy is a concern for the client's treatment but does not pose an immediate risk to their safety.

A. Maintain a quiet, non-stimulating environment. B. Force oral fluids and provide frequent small meals C. Confront the client's denial of substance abuse. D. Encourage attendance and group participation.

Correct Answer is A

Explanation

A. A quiet, non-stimulating environment helps reduce sensory overload and agitation, which are common in alcohol withdrawal delirium.
B. While hydration and nutrition are important, they are not as immediately critical as managing environmental stimuli.
C. Confronting the client's denial is a part of psychological therapy but not the most immediate concern during acute withdrawal delirium.
D. Group participation may be too stimulating for a client in acute withdrawal and can exacerbate symptoms.

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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)

Nursing Test Bank

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