The nurse is preparing to administer medications through a tube.
Which of the following should she remember before administering the medications?

Have the patient lie flat before administering the medications.

Administer the medications if the residual is 200 ml or more.

Mix all medications together before putting them through the tube.

Elevate the head of the patient's bed at least 30 degrees before administering the medications.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Having the patient lie flat before administering medications through a tube increases the risk of aspiration, as gastric contents can reflux into the esophagus and potentially enter the airway. Proper patient positioning is crucial to promote safe medication delivery and prevent pulmonary complications.

Choice B rationale

Administering medications when gastric residual volume is 200 mL or more is generally not recommended. A high residual volume indicates delayed gastric emptying, increasing the risk of aspiration and potentially affecting medication absorption. Typically, residuals of 200-250 mL or more warrant holding the feeding and reassessing.

Choice C rationale

Mixing all medications together before administration is often inappropriate and can lead to several problems. Drug incompatibilities can occur, altering medication effectiveness, causing precipitation, or leading to tube occlusion. Each medication should generally be administered separately, flushed with water between doses.

Choice D rationale

Elevating the head of the patient's bed to at least 30 degrees before administering medications through a tube significantly reduces the risk of aspiration. This semi-Fowler's position utilizes gravity to keep gastric contents in the stomach, promoting safe passage of medications and minimizing reflux into the esophagus and lungs.

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Correct Answer is C

Explanation

Choice A rationale

Pain sensation behind the eyes, particularly during palpation of the frontal or ethmoid sinuses, suggests inflammation or infection within these sinuses. Under normal conditions, healthy paranasal sinuses are air-filled cavities and should not elicit pain upon palpation.

Choice B rationale

Pain during palpation of any sinus area is indicative of sinusitis or inflammation. The presence of pain signifies pressure buildup, mucosal edema, or infection within the sinus cavities. Normal findings would not involve pain, but rather a sensation of mild pressure.

Choice C rationale

Normal findings during sinus palpation should elicit a sensation of pressure but no pain or tenderness. This indicates that the sinuses are air-filled, patent, and free from inflammation or congestion. The pressure is a result of the gentle digital compression over the bony structures.

Choice D rationale

Tingling along the nose and eyes is not a typical sensation associated with normal sinus palpation. This sensation might suggest neurological irritation, such as nerve compression or neuropathy, rather than a direct physiological response from the paranasal sinuses themselves.

A. Ask the patient about a history of frostbite. B. Suspect that the patient has venous insufficiency. C. Consider this a delayed capillary refill time, and investigate further. D. Consider this a normal capillary refill time that requires no further assessment.

Correct Answer is C

Explanation

Choice A rationale

Frostbite causes localized tissue damage due to ice crystal formation and cellular dehydration, leading to impaired circulation. While frostbite can affect capillary refill, a 5-second refill time in the absence of cold exposure or other correlating symptoms makes frostbite a less likely primary consideration and requires broader assessment.

Choice B rationale

Venous insufficiency involves impaired blood return to the heart, leading to venous stasis and edema. Capillary refill primarily assesses arterial perfusion and microcirculatory integrity, not venous outflow. Therefore, venous insufficiency would not typically manifest as a prolonged capillary refill time as a primary symptom.

Choice C rationale

Normal capillary refill time in adults is typically less than 2 seconds. A 5-second capillary refill time indicates impaired peripheral perfusion, suggesting inadequate blood flow to the capillaries. This delay warrants further investigation to identify underlying causes such as dehydration, hypovolemia, or peripheral vascular compromise.

Choice D rationale

Normal capillary refill time is typically less than 2 seconds. A 5-second refill time is significantly prolonged and indicates compromised peripheral circulation. Considering this normal would lead to a missed opportunity to identify and address a potentially serious underlying physiological issue affecting tissue perfusion.

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The nurse is preparing to administer medications through a tube. Which of the following should she remember before administering the medications?

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The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation?

Correct Answer is C

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Explanation

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The nurse is preparing to administer medications through a tube.
Which of the following should she remember before administering the medications?