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 ["100"]
Explanation
Step 1 is calculate the flow rate in mL/hr. 100 mL ÷ 60 minutes = 1.666 mL/minute. 1.666 mL/minute × 60 minutes/hr = 99.96 mL/hr. Rounded to whole number: 100 mL/hr.
Correct Answer is A
Explanation
Choice A rationale
The vastus lateralis muscle is the preferred intramuscular injection site for infants and children due to its large muscle mass and lack of major nerves or blood vessels, minimizing the risk of injury. This site is easily accessible and provides a safe area for medication absorption in developing musculature.
Choice B rationale
The ventrogluteal site is generally considered safe and effective for intramuscular injections, but it requires precise anatomical landmark identification, which can be challenging in infants and young children, increasing the risk of sciatic nerve injury if landmarks are not accurately identified.
Choice C rationale
The dorsogluteal site is contraindicated for intramuscular injections in infants and children due to the risk of sciatic nerve damage. The sciatic nerve runs through this area, and the muscle mass is not fully developed in younger patients, making it a hazardous site.
Choice D rationale
The deltoid muscle is too small and underdeveloped in infants and young children to safely accommodate intramuscular injections. Its limited muscle mass increases the risk of injury to underlying nerves and blood vessels, and absorption capacity is reduced.
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