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 15-degree angle is typically used for intradermal injections, where the medication is deposited just beneath the epidermis to form a bleb, not for subcutaneous injections which target the adipose tissue layer. Taut skin is also incorrect for subcutaneous.
Choice B rationale
For an average-sized client receiving a subcutaneous injection, a 45-degree angle facilitates optimal medication deposition into the subcutaneous adipose tissue layer. Pinching the skin helps to elevate the subcutaneous tissue away from underlying muscle, reducing the risk of intramuscular injection.
Choice C rationale
A 90-degree angle is typically used for intramuscular injections in most adults, aiming to deposit medication deep into muscle tissue. Stretching the skin is generally more appropriate for intramuscular injections rather than subcutaneous.
Choice D rationale
Z-tracking is a technique primarily used for intramuscular injections of irritating medications to prevent leakage back into subcutaneous tissue. It is not a standard technique for subcutaneous injections, which use a different angle and skin manipulation.
Correct Answer is C
Explanation
Choice A rationale
Inspection, as the initial assessment technique, relies on keen observation and often feels natural and comfortable for experienced practitioners. Expertise enhances the ability to systematically identify subtle visual cues, skin color changes, or movement abnormalities. The discomfort suggestion is incongruent with the skilled and focused nature of effective clinical inspection.
Choice B rationale
Inspection demands a comprehensive, unhurried visual assessment, not just a quick glance. A thorough inspection involves observing body systems methodically, noting details like symmetry, posture, gait, and superficial lesions. Rushing this phase can lead to missed crucial information, as many conditions present with visible signs that require careful scrutiny.
Choice C rationale
The inspection phase is foundational and remarkably informative, providing extensive data through meticulous observation of visible characteristics. It encompasses general appearance, facial expressions, body symmetry, skin condition, and respiratory effort. This detailed visual survey often reveals significant diagnostic clues even before physical contact, guiding subsequent assessment steps.
Choice D rationale
Inspection is an exceptionally rich source of information, contrary to yielding little. It provides a holistic view of the patient's immediate condition, including their overall demeanor, signs of distress, nutritional status, and any overt physical abnormalities. Many diagnoses are initially suggested or confirmed through careful visual inspection, making it indispensable.
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