The nurse is performing an assessment on a patient and asks the patient to close their eyes and places a familiar object in the patient's hand.

The nurse asks the patient to identify the object.
This is known as:

Choice A rationale

Turning the patient to the right side immediately after medication administration via a tube is generally not recommended as it may promote rapid gastric emptying which can potentially lead to dumping syndrome or alter drug absorption by moving the medication out of the stomach too quickly.

Choice B rationale

Leaving the patient in a high-Fowler's position for 30 minutes after administering medications through a tube helps prevent aspiration by utilizing gravity to keep the medication in the stomach. This position also aids in proper digestion and absorption by maintaining gastrointestinal motility and reducing reflux.

Choice C rationale

Flushing the tube with 10-15 mL of water after each medication is generally insufficient to clear the tube effectively and prevent clogging, especially with viscous medications. A standard flush volume of 30-60 mL is typically recommended to ensure complete medication delivery and tube patency.

Choice D rationale

Holding medication if 50 mL of residual is obtained is not a universal standard. The acceptable residual volume varies based on institutional policy, patient condition, and the type of feeding. Often, a residual volume of 200-250 mL or more is the threshold for holding medications.

Choice A rationale

Surgical history provides context regarding past medical interventions and potential anatomical alterations. While relevant for comprehensive patient assessment, it does not directly impact the immediate safety of medication administration in the same critical manner as identifying drug hypersensitivities, which can precipitate life-threatening anaphylactic reactions.

Choice B rationale

Drug tolerance refers to a diminished physiological response to a medication over time, requiring increased doses to achieve the same effect. While important for therapeutic efficacy and dose adjustment, it is secondary to the immediate danger posed by an allergic reaction, which can be acute and severe.

Choice C rationale

Diet history is crucial for identifying potential drug-food interactions or nutritional deficiencies that might influence medication absorption or metabolism. However, an adverse food interaction, while potentially problematic, typically poses less immediate and severe risk than an unknown drug allergy, which can be fatal.

Choice D rationale

Allergy history is paramount because exposure to an allergen can trigger a severe, potentially life-threatening immunological response, such as anaphylaxis. Identifying known allergies prevents direct exposure to the offending agent, thereby safeguarding the patient from acute hypersensitivity reactions and ensuring immediate patient safety.