The nurse has a prescription to give 30 mL of an antacid to a ...

[stephzh]

The nurse has a prescription to give 30 mL of an antacid to a client through a feeding tube. Which of the following is a priority nursing action?
 
  1. Assess tube placement.
  2. Administer the antacid by gravity flow.
  3. Aspirate to determine residual volume.
  4. Follow medication administration with 30 mL of sterile saline.

Question 2

The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS) who is receiving foscarnet (Foscavir).
 
  The nurse reviews the physician's prescriptions, expecting to note a prescription for which of the following laboratory tests while this client is taking the medication? 1. CD4+ cell count
  2. Serum albumin level
  3. Serum creatinine level
  4. Lymphocyte count

[xthemafja]

Answer to Question 1

1

Rationale: Although each of the actions in the options is important, evaluation of tube placement is the priority to prevent aspiration and to ensure that medication delivery will be in the stomach.

Answer to Question 2

3

Rationale: Foscavir is very toxic to the kidneys. Serum creatinine is monitored prior to therapy, 2 to 3 times weekly during induction therapy, and at least once weekly during maintenance therapy. It also may cause decreased levels of calcium, magnesium, phosphorus, and potassium in the bloodstream. Thus, these levels also are measured with the same frequency. The laboratory tests in CD4+ cell count, serum albumin level, and lymphocyte count are not specific to the medication.