The nurse is preparing to assess the posterior tibial pulse.
Where is the correct location for palpation?

Choice A rationale

Instilling water to rinse the tube is an important step after medication administration or prior to administering incompatible medications, but it is not the initial and most crucial step before delivering any drug. Placement verification is paramount.

Choice B rationale

Scientifically, confirming tube placement is the absolute first and most critical step before administering any substance, including medication, through an enteral tube. Misplaced tubes can lead to aspiration pneumonia or inefficient drug absorption, posing significant patient safety risks.

Choice C rationale

Laying the client flat may increase the risk of aspiration, especially if the tube is misplaced or if the client has impaired gag reflex. Proper positioning, typically semi-Fowler's, is crucial for safe enteral feeding and medication administration.

Choice D rationale

Assessing bowel sounds is important for evaluating gastrointestinal motility and absorption capacity before initiating or continuing enteral feedings, but it is not the primary immediate safety check required before administering a single dose of medication.

Choice A rationale

While documenting additional clothing could mitigate some error, the presence of a jacket and shoes adds variable, unmeasured mass. Accurate weight measurement is crucial for medication dosing, fluid balance assessment, and nutritional status monitoring. Even seemingly minor additions can significantly skew results, impacting clinical decisions and potentially leading to suboptimal patient care.

Choice B rationale

The type of scale significantly impacts accuracy and precision. Different scales, such as beam scales, electronic scales, or bed scales, have varying calibration standards and sensitivities. Using a consistent, properly calibrated scale minimizes measurement variability and ensures reliable data, which is essential for tracking trends and making valid comparisons over time in a clinical setting.

Choice C rationale

Diurnal variations in body weight occur due to factors like fluid shifts, food and fluid intake, and bowel elimination. Weighing at the same time minimizes these transient fluctuations, providing a more consistent and comparable baseline for monitoring weight changes over time. This consistency is vital for accurate assessment of a patient's fluid status, nutritional progress, or response to therapeutic interventions.

Choice D rationale

While weighing in undergarments provides the most accurate baseline, it may not always be practical or appropriate due to patient comfort, privacy concerns, or clinical urgency. The goal is to standardize the weighing procedure as much as possible, including minimizing clothing and documenting any deviations to ensure consistency and interpretability of serial weight measurements.