The nurse observes a student nurse administer 100 mg phenytoin (Dilantin) suspension and 20 mg famotidine (Pepcid) solution through a gastrostomy tube. The client receives an enteral feeding through the gastrostomy tube at a rate of 75 mL/h. Which action by the student nurse requires an IMMEDIATE intervention by the nurse?

The student nurse flushes the gastrostomy tube with 15 mL water between medications.

The student nurse reinserts 50 mL stomach contents after aspiration of the gastrostomy tube.

The student nurse checks the pH of the gastric aspirate prior to flushing the gastrostomy tube.

The student nurse reconnects the enteral feeding immediately after the medication is given.

Answer and Explanation

The Correct Answer is D

Choice A reason: Flushing with 15 mL water between medications is correct to prevent clogging and ensure delivery. Immediate feeding reconnection risks phenytoin absorption, making this incorrect, as it’s a proper action unlike the error requiring the nurse’s immediate intervention.

Choice B reason: Reinserting 50 mL of aspirated stomach contents is acceptable to maintain fluid balance. Reconnecting feeding immediately affects phenytoin efficacy, making this incorrect, as it’s a correct action compared to the student’s error needing the nurse’s urgent correction.

Choice C reason: Checking gastric aspirate pH confirms tube placement, a safety step. Immediate feeding reconnection reduces phenytoin absorption, making this incorrect, as it’s a proper action unlike the student’s mistake requiring the nurse’s immediate intervention for medication administration.

Choice D reason: Reconnecting enteral feeding immediately after phenytoin reduces its absorption, as feedings should be held for 1-2 hours. This requires immediate intervention, aligning with medication administration protocols, making it the correct action for the nurse to address in the student’s care.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Rolling down tight stockings creates a tourniquet effect, worsening venous insufficiency. Elevating feet improves circulation, making this incorrect, as it reflects a misunderstanding of compression therapy compared to the correct management taught by the nurse for venous insufficiency.

Choice B reason: Putting on stockings after swelling begins is less effective than wearing them preventatively. Elevating feet reduces edema, making this incorrect, as it shows partial understanding compared to the proactive elevation strategy indicating full comprehension of the nurse’s teaching.

Choice C reason: Elevating feet when sitting promotes venous return, reducing edema in venous insufficiency. This aligns with self-care education for the condition, making it the correct statement, as it demonstrates the client’s accurate understanding of the nurse’s teaching to manage lower extremity swelling.

Choice D reason: Crossing legs impairs venous return, exacerbating venous insufficiency, regardless of duration. Elevating feet is correct, making this incorrect, as it reflects a misconception about safe practices compared to the nurse’s teaching on managing venous insufficiency effectively.

A. Assessing blood pressure. B. Measuring intake and output. C. Elevating the head of the bed. D. Checking for presence of dependent edema.

Correct Answer is C

Explanation

Choice A reason: Assessing blood pressure monitors fluid overload but doesn’t immediately reduce respiratory strain. Elevating the head of the bed improves breathing, making this incorrect, as it’s less urgent than the nurse’s first action to prevent harm from fluid overload.

Choice B reason: Measuring intake and output tracks fluid balance but is less immediate than elevating the bed to ease breathing. This is incorrect, as it delays the nurse’s priority action to alleviate respiratory distress in a client with suspected fluid overload.

Choice C reason: Elevating the head of the bed is the first action to reduce respiratory distress in fluid overload by decreasing venous return. This aligns with acute care priorities, making it the correct action to prevent harm in the client with suspected hypervolemia.

Choice D reason: Checking for dependent edema confirms fluid overload but doesn’t address immediate respiratory risks. Elevating the bed is urgent, making this incorrect, as it’s secondary to the nurse’s first action to improve breathing in the fluid-overloaded client.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload?

Correct Answer is C

Explanation

A nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following adverse effects of the medication?

The nurse is providing dietary education to a client with gastroesophageal reflux disease (GERD). The nurse indicates that the client understands the teaching if the client states a plan to avoid which foods to prevent symptom exacerbation? (Select all that apply)

The nurse is caring for a client with ulcerative colitis. Which findings does the nurse determine is consistent with this diagnosis? (Select all that apply)

Which assessments are most important for the nurse to perform to prevent harm on a client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply)

The primary health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?