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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A stat medication order signifies an immediate and urgent administration of the drug, typically within 30 minutes of the order. This is for critical situations where delay could significantly impact patient outcome, requiring prompt action rather than nurse's judgment for necessity.
Choice B rationale
A PRN (pro re nata) medication order means "as needed.”. This type of order grants the nurse professional discretion to administer the medication based on their assessment of the patient's condition and the specific criteria outlined in the order, such as pain level or fever.
Choice C rationale
A scheduled medication order involves administering the drug at regularly prescribed intervals, such as every 8 hours or once daily. The timing is predetermined, and the nurse's primary role is adherence to the schedule, with less independent judgment regarding administration necessity.
Choice D rationale
A single-dose order is for a medication to be given only once at a specific time. This is often used for preoperative medications or diagnostic procedures. Like scheduled orders, the timing is set, and the nurse's judgment about the necessity of administration is not the primary factor.
Correct Answer is B
Explanation
Choice A rationale
Changes in peripheral vision in response to light are not directly related to visual accommodation. Peripheral vision is mediated by rod photoreceptors and is assessed through visual field testing, whereas accommodation involves the crystalline lens and its ability to change shape for focusing.
Choice B rationale
Visual accommodation is the process by which the eye changes its optical power to maintain a clear image or focus on an object as its distance varies. When looking at a near object, the ciliary muscles contract, relaxing the suspensory ligaments, allowing the lens to become more convex (thicker) to increase refractive power. This change in lens shape is accompanied by pupillary constriction (miosis) and convergence of the visual axes (medial movement of the eyeballs) to maintain binocular vision.
Choice C rationale
Involuntary blinking in the presence of bright light is a reflex action called the blink reflex, serving to protect the eye from excessive light and maintain lubrication. It is a protective mechanism and not a component of the physiological process of visual accommodation, which focuses on near objects.
Choice D rationale
Dilation of the pupils (mydriasis) occurs when looking at a far object or in dim light conditions to allow more light to enter the eye. This is regulated by the sympathetic nervous system and is opposite to the pupillary constriction that accompanies accommodation for near vision.
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