The nurse is preparing to administer a medication via a nasogastric tube. Which guideline is appropriate for the nurse to follow when administering a drug via this route?

If connected to suction, do not reconnect to suction for 5 minutes after drug administration.

Administer the medication at a cold temperature

Position the client supine prior to administering the drug

Flush the tube with water between each drug administered

Answer and Explanation

The Correct Answer is D

A. If connected to suction, do not reconnect to suction for 5 minutes after drug administration: The nurse should actually clamp or disconnect suction during and for at least 30 minutes after administration to allow absorption, so 5 minutes is insufficient.

B. Administer the medication at a cold temperature: Medications should be administered at room temperature to prevent gastric discomfort or cramping. Cold medications can cause nausea or spasms.

C. Position the client supine prior to administering the drug: The client should be positioned upright or with the head of the bed elevated (at least 30–45 degrees) to reduce risk of aspiration during administration.

D. Flush the tube with water between each drug administered: Flushing the nasogastric tube with water before, between, and after medications prevents clogging and ensures proper delivery of each drug and helps prevent drug incompatibilities.

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Correct Answer is A,B,D,E,C

Explanation

A. Open the airway using a jaw-thrust maneuver: The first priority in a primary survey is airway management, especially in trauma cases. The jaw-thrust technique is used to maintain cervical spine alignment while opening the airway.

B. Assess the use of accessory muscles and rate of respirations: After the airway is secured, breathing is assessed next. Observing for respiratory effort and accessory muscle use helps determine respiratory function and oxygenation needs.

D. Assess blood pressure and heart rate: The next priority is circulation, which involves checking for adequate perfusion. Vital signs like heart rate and blood pressure provide critical information about circulatory status.

E. Perform a Glasgow Coma Scale assessment: Once ABCs are stable, disability is assessed using neurological tools like the GCS to evaluate consciousness and identify any brain injury.

C. Remove clothing for a thorough assessment: Exposure is the last step in the primary survey. Clothing is removed to fully inspect for other injuries while maintaining temperature control to prevent hypothermia.

A. stage 4 pressure injury B. stage 3 pressure injury C. stage 2 pressure injury D. stage 1 pressure injury

Correct Answer is B

Explanation

A. stage 4 pressure injury: A stage 4 pressure injury involves full-thickness skin and tissue loss with exposed bone, tendon, or muscle, which is beyond subcutaneous tissue damage. These wounds may also include undermining or tunneling and carry a high risk for infection.

B. stage 3 pressure injury: Stage 3 pressure injuries involve full-thickness skin loss that extends into the subcutaneous tissue but does not expose bone, tendon, or muscle, aligning with the description of the wound. This stage may also include slough, undermining, or tunneling.

C. stage 2 pressure injury: A stage 2 injury involves partial-thickness skin loss with exposure of the dermis, typically presenting as a shallow open ulcer, not reaching subcutaneous layers. It may also appear as an intact or ruptured serum-filled blister.

D. stage 1 pressure injury: Stage 1 is characterized by non-blanchable erythema of intact skin without any tissue loss or damage to deeper layers.

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The nurse is preparing to administer a medication via a nasogastric tube. Which guideline is appropriate for the nurse to follow when administering a drug via this route?

Nursing Test Bank

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Explanation

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Correct Answer is B

Explanation

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