The charge nurse observes a new nurse during the administration of two different liquid medications at once through a gastrostomy tube used for enteral feeding. The charge nurse observes the new nurse's actions, as seen in the video. What action(s) should the charge nurse take? (Select all that apply.)

Encourage the novice to flush the tube with more water.

Instruct the novice to administer each medication separately.

Add the liquid volumes when documenting fluid intake.

Confirm that the novice determined the amount of gastric residual.

Advise the novice to use the plunger when giving medications.

Answer and Explanation

Correct Answer : A,B,C,D

The correct answer is A, B, C, and D.

Choice A reason: Flushing the gastrostomy tube with water is essential to maintain tube patency and prevent medication interactions. It should be done before and after medication administration. The typical amount of water used for flushing can range from 15 to 30 mL.

Choice B reason: Administering each medication separately is a critical practice to prevent drug interactions and ensure that the full dose of each medication is delivered. It also helps in preventing the clogging of the tube.

Choice C reason: Documenting all liquid volumes, including medications and water used for flushing, is important for accurate fluid intake records. This helps in maintaining fluid balance and monitoring the patient’s hydration status.

Choice D reason: Checking gastric residual volume is important to assess the patient’s tolerance to enteral feeding and to prevent complications such as aspiration. Normal gastric residual volumes are generally considered to be less than 250 mL.

Choice E reason: Using a plunger to administer medications through a gastrostomy tube is not always recommended. Medications should be administered slowly to prevent discomfort or harm, and the use of a plunger is not a standard practice across all healthcare settings.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice A is correct because the nurse's priority is to provide comfort and dignity to the dying patient. Pain management is an essential aspect of end-of-life care.

Choice B is incorrect because updating the nurse manager is not a priority action. The nurse manager can be informed later, after the patient's needs are met.

Choice C is incorrect because conveying the patient's status to the chaplain is not a priority action. The chaplain can be contacted later, after the patient's needs are met. The chaplain may also need the consent of the patient or the family before providing spiritual support.

Choice D is incorrect because documenting the impending signs of death is not a priority action. Documentation can be done later, after the patient's needs are met. Documentation is important, but not as important as providing comfort and dignity to the dying patient.

A. Provide disposable training pants while calming the mother. B. Refer the mother to a community parent education program. C. Suggest that the mother consult a pediatric nephrologist. D. Inform the mother that toilet training is slower for boys.

Correct Answer is A

Explanation

Choice A reason: This is correct because it addresses both the physical and emotional needs of the child and the mother. The nurse should provide comfort and reassurance to the mother and explain that occasional accidents are normal and not a sign of failure.

Choice B reason: This is incorrect because it implies that the mother is incompetent and needs external help. The nurse should first establish rapport and trust with the mother before suggesting any resources or interventions.

Choice C reason: This is incorrect because it suggests that there is something wrong with the child's kidneys, which may alarm and offend the mother. The nurse should not jump to conclusions without assessing the child's history and symptoms.

Choice D reason: This is incorrect because it generalizes and stereotypes boys as being slower than girls in toilet training. The nurse should not make assumptions based on gender and should respect individual differences.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A dietitian with a prescription for no not resuscitate (DNR) begins to manifest signs of impending death. After notifying the family of the patient's status, what priority action should the nurse implement?

Correct Answer is A

Explanation

The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3-year-old son for wetting his pants. What initial action should the nurse take?

Correct Answer is A

Explanation

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin 500 mg PO twice daily. Which statement(s) should the nurse include in this client’s teaching plan? (Select all that apply.)

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet?

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

The client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) don gloves and a gown to assist the client. Which action should the nurse take?

A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?

A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet?