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The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. Which action isbestfor the nurseto take?
- A. Instill nonliquid medications without diluting.
- B. Irrigate the tube with 60 mL of water after all medications are given.
- C. Mix all medications together to decrease the number of administrations.
- D. Check with the pharmacy for availability of the liquid forms of medications.
Correct Answer: D
Rationale: Rationale for Correct Answer (D): Checking with the pharmacy for availability of liquid forms of medications is the best action because it reduces the risk of clogging the nasogastric tube. Liquid medications are less likely to cause blockages compared to nonliquid medications. Additionally, liquid forms are easier to administer through the tube. By using liquid medications, the nurse can ensure that the medications flow smoothly through the tube without causing any obstructions.
Summary of Incorrect Choices:
A: Instilling nonliquid medications without diluting can increase the risk of tube clogging.
B: Irrigating the tube with water after all medications are given may not prevent clogging effectively and could introduce unnecessary moisture into the tube.
C: Mixing all medications together can lead to potential drug interactions and may not address the issue of tube clogging effectively.
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An oncology nurse is caring for a patient who has developed erythema following radiation therapy. What should the nurse instruct the patient to do?
- A. Periodically apply ice to the area.
- B. Keep the area cleanly shaven.
- C. Apply petroleum jelly to the affected area.
- D. Avoid using soap on the treatment area.
Correct Answer: C
Rationale: The correct answer is C: Apply petroleum jelly to the affected area. This is because petroleum jelly helps to soothe and protect the skin, reducing dryness and irritation caused by radiation therapy. Ice (A) can further damage the skin, shaving (B) can increase the risk of infection, and soap (D) can be too harsh on the sensitive skin. Therefore, instructing the patient to apply petroleum jelly is the most appropriate recommendation to promote skin healing and comfort.
As the American population ages, nurses expect see more patients admitted to long-term care facilities in need of palliative care. Regulations now in place that govern how the care in these facilities is both organized and reimbursed emphasize what aspect of care?
- A. Ongoing acute care
- B. Restorative measures
- C. Mobility and socialization
- D. Incentives to palliative care
Correct Answer: D
Rationale: The correct answer is D: Incentives to palliative care. Palliative care focuses on improving the quality of life for patients with serious illnesses by addressing their physical, emotional, and spiritual needs. As the American population ages, the emphasis on palliative care in long-term care facilities is crucial. Regulations emphasizing incentives for palliative care ensure that patients receive appropriate symptom management, comfort care, and support to enhance their overall well-being.
Choice A: Ongoing acute care is not the correct answer because palliative care is different from acute care, which focuses on treating the underlying medical condition.
Choice B: Restorative measures are not the correct answer as palliative care aims to improve quality of life rather than focusing on restoring physical function.
Choice C: Mobility and socialization are important aspects of care in long-term facilities, but palliative care goes beyond these aspects to provide holistic support for patients facing serious illnesses.
A labor and birth nurse receives a call from the laboratory regarding a preeclamptic patient receiving an IV infusion of magnesium sulfate. The laboratory technician reports that the patient’s magnesium level is 6 mg/dL. What is the nurse’s priority action?
- A. Stop the infusion of magnesium.
- B. Assess the patient’s respiratory rate.
- C. Assess the patient’s deep tendon reflexes.
- D. Notify the health care provider of the magnesium level.
Correct Answer: A
Rationale: The correct answer is A: Stop the infusion of magnesium. A magnesium level of 6 mg/dL is above the therapeutic range (4-7 mg/dL) for preeclamptic patients receiving magnesium sulfate. Continuing the infusion can lead to magnesium toxicity, causing respiratory depression, cardiac arrest, and neuromuscular blockade. Stopping the infusion is crucial to prevent further complications. Assessing the patient's respiratory rate (B) and deep tendon reflexes (C) are important, but stopping the infusion takes priority to prevent harm. Notifying the health care provider (D) is important but may delay immediate action to address the high magnesium level.
A patient with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine (Tegretol) for pain relief. What principle applies to the administration of this medication?
- A. Tegretol is not known to have serious adverse effects.
- B. The patient should be monitored for bone marrow depression.
- C. Side effects of the medication include renal dysfunction.
- D. The medication should be first taken in the maximum dosage form to be effective.
Correct Answer: B
Rationale: The correct answer is B: The patient should be monitored for bone marrow depression. Carbamazepine can cause bone marrow suppression, leading to decreased production of blood cells. Monitoring blood counts is crucial to detect this adverse effect early. Choice A is incorrect as Tegretol can have serious adverse effects, including bone marrow depression. Choice C is incorrect as the main side effects of carbamazepine are related to the central nervous system, not renal dysfunction. Choice D is incorrect as medications like carbamazepine should be started at a low dose and gradually titrated up to minimize side effects.
A patient newly diagnosed with a cervical disk herniation is receiving health education from the clinic nurse. What conservative management measures should the nurse teach the patient to implement?
- A. Perform active ROM exercises three times daily.
- B. Sleep on a firm mattress.
- C. Apply cool compresses to the back of the neck daily.
- D. Wear the cervical collar for at least 2 hours at a time.
Correct Answer: B
Rationale: The correct answer is B: Sleep on a firm mattress. A firm mattress helps maintain proper spinal alignment, reducing pressure on the cervical spine. This promotes healing and prevents worsening of symptoms.
A: Performing active ROM exercises may exacerbate symptoms and worsen the condition.
C: Applying cool compresses may provide temporary relief but does not address the underlying issue of spinal alignment.
D: Wearing a cervical collar for extended periods can weaken neck muscles and hinder natural healing processes.
In summary, sleeping on a firm mattress is the most appropriate conservative measure as it supports proper spinal alignment.