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A healthcare provider is planning to administer medications to a client who is receiving enteral feedings through an NG tube. Which of the following actions should the healthcare provider plan to take?
- A. Dissolve each medication in 5 mL of sterile water.
- B. Administer medications through a secondary infusion.
- C. Mix medications with the enteral feeding.
- D. Flush the NG tube with 30 mL of water before and after administering medications.
Correct Answer: D
Rationale: Flushing the NG tube with water before and after administering medications is essential to prevent clogging of the tube and ensure proper delivery of medication. This practice helps maintain tube patency and decreases the risk of obstruction, which could compromise the client's treatment and nutrition. By flushing the tube, the healthcare provider ensures that the medication is completely delivered and that there are no residual drug particles left in the tube, which could lead to blockages or inconsistent dosing. Therefore, flushing the NG tube is a crucial step in the safe administration of medications to clients receiving enteral feedings.
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Which of the following statement is NOT true about developmental stages?
- A. Based on age only
- B. Includes physical changes
- C. Includes psychosocial changes
- D. Proposed by Erikson
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is providing endotracheal suctioning to a client who is mechanically ventilated, when the client becomes restless and tachycardic. Which action should the nurse take?
- A. Notify the health care provider as soon as possible.
- B. Contact the respiratory department to suction the client.
- C. Hyperoxygenate and hyperventilate the client with an Ambu bag and resuction.
- D. Monitor vital signs and discontinue attempts at suctioning until the client is stabilized.
Correct Answer: D
Rationale: Restlessness and tachycardia during suctioning suggest hypoxia or distress; discontinuing suctioning and monitoring vital signs (D) is the priority to stabilize the client. Notifying the provider (A) or respiratory (B) delays immediate action. Hyperoxygenating and resuctioning (C) risks worsening hypoxia. D is correct. Rationale: Stopping suctioning halts oxygen depletion, allowing recovery, while monitoring guides further intervention, a standard response per airway management protocols. This prevents complications like arrhythmias or desaturation, prioritizing patient safety over premature escalation or repeated procedures in an unstable state.
A healthcare provider is preparing to administer an intramuscular injection to an adult client. Which of the following injection sites should the healthcare provider select?
- A. Deltoid muscle
- B. Dorsogluteal muscle
- C. Vastus lateralis muscle
- D. Rectus femoris muscle
Correct Answer: A
Rationale: The deltoid muscle is a common site for intramuscular injections in adults due to its accessibility and muscle mass. It is located in the upper arm and provides a sufficient area for injection. The deltoid muscle is preferred for administering vaccines and other medications that require IM administration.
When teaching a client with a new diagnosis of diabetes mellitus about foot care, which of the following instructions should the nurse include?
- A. Soak your feet in hot water every day.
- B. Apply lotion between your toes.
- C. Inspect your feet daily.
- D. Use over-the-counter products to remove corns.
Correct Answer: C
Rationale: Inspecting the feet daily is crucial for clients with diabetes mellitus to detect early signs of injury or infection promptly. This practice helps prevent serious complications such as diabetic foot ulcers. Soaking feet in hot water daily can lead to skin dryness and increase the risk of injury. Applying lotion between toes can cause moisture buildup, leading to fungal infections. Using over-the-counter products to remove corns can result in skin damage and should be done under healthcare provider supervision.
A client has a new prescription for total parenteral nutrition (TPN). Which of the following actions should the nurse plan to take?
- A. Obtain a random blood glucose daily.
- B. Change the IV tubing every 72 hours.
- C. Apply a new dressing to the IV site every 24 hours.
- D. Weigh the client weekly.
Correct Answer: A
Rationale: When a client is on total parenteral nutrition (TPN), monitoring blood glucose levels daily is crucial to manage and detect complications like hyperglycemia, which can occur due to the high glucose content in TPN solutions. Regular blood glucose monitoring helps the healthcare team adjust the TPN infusion rate to maintain optimal glucose levels and prevent adverse events.