The nurse is preparing to examine a patient complaining of right lower quadrant (RLQ) pain.
Which technique is correct during the assessment? The nurse should:

Choice A rationale

A standing order is a pre-written medication order and protocol that applies to a specific patient population or clinical situation, allowing nurses to initiate treatment without immediate physician consultation. While it provides a framework, a daily medication is more specifically classified by its regular administration schedule, distinguishing it from general standing orders.

Choice B rationale

A routine order signifies a medication order that is carried out as prescribed until a discontinuation order or change is made. The medication is given on a regular, scheduled basis, often daily, multiple times a day, or weekly. This ensures consistent therapeutic levels for chronic conditions. Lasix 40 mg PO daily fits this description, as it is given consistently each day.

Choice C rationale

A STAT order (statim) means "immediately" and indicates that the medication must be administered as soon as possible, typically within 30 minutes of the order. This type of order is reserved for urgent situations where delay could significantly impact patient outcomes. Lasix ordered daily does not fall into this urgent category.

Choice D rationale

A PRN order (pro re nata) means "as needed.”. This type of order allows the nurse to administer medication based on the patient's symptoms or specific criteria rather than on a fixed schedule. Since Lasix is ordered "daily," it implies a fixed schedule, not an "as needed" administration.

Choice A rationale

Turning the patient to the right side immediately after medication administration via a tube is generally not recommended as it may promote rapid gastric emptying which can potentially lead to dumping syndrome or alter drug absorption by moving the medication out of the stomach too quickly.

Choice B rationale

Leaving the patient in a high-Fowler's position for 30 minutes after administering medications through a tube helps prevent aspiration by utilizing gravity to keep the medication in the stomach. This position also aids in proper digestion and absorption by maintaining gastrointestinal motility and reducing reflux.

Choice C rationale

Flushing the tube with 10-15 mL of water after each medication is generally insufficient to clear the tube effectively and prevent clogging, especially with viscous medications. A standard flush volume of 30-60 mL is typically recommended to ensure complete medication delivery and tube patency.

Choice D rationale

Holding medication if 50 mL of residual is obtained is not a universal standard. The acceptable residual volume varies based on institutional policy, patient condition, and the type of feeding. Often, a residual volume of 200-250 mL or more is the threshold for holding medications.