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
Using a large bore needle (e.g., 18-gauge) for withdrawing medication from an ampule is generally avoided unless the medication is highly viscous, because it can create a larger hole in the ampule, increasing the risk of glass particle introduction. The primary concern with ampules is preventing glass shards from entering the syringe, which is addressed by filtration, not needle bore size alone.
Choice B rationale
Ampules are single-dose glass containers. When an ampule is opened, small, invisible glass fragments can break off. A filter needle contains a microscopic filter that traps these glass particles, preventing their aspiration into the syringe and subsequent injection into the patient, thus mitigating the risk of phlebitis, emboli, or other complications from particulate matter.
Choice C rationale
A small gauge needle (e.g., 25-gauge) has a very narrow lumen, which would make withdrawing medication from an ampule unnecessarily difficult and slow, especially for viscous solutions. Furthermore, a small gauge needle does not mitigate the risk of glass particle aspiration, which is the paramount concern when withdrawing medication from a glass ampule.
Choice D rationale
Placing a cotton ball over the opening of an ampule is not a scientifically sound method to prevent being cut or to prevent glass shards from entering the medication. Ampules are designed to be broken cleanly. Proper ampule opening techniques and the use of a filter needle are the established safety measures to prevent injury and contamination.
Correct Answer is ["50"]
Explanation
Step 1 is to calculate the total drops to be infused. 100 mL × 15 gtt/mL = 1500 gtt.
Step 2 is to calculate the flow rate in drops per minute. 1500 gtt ÷ 30 minutes = 50 gtt/min. The final calculated answer is 50 gtt/min
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