Chapter 9: Enteral Administration
Test Bank
MULTIPLE CHOICE
1. In which position would the nurse place a patient before the administration of an enteral feeding?
a.
Supine
b.
Semi-Fowlers
c.
Left lateral
d.
Prone
ANS: B
To facilitate gastric emptying, the patient should be placed in a semi-Fowlers position (30 degree head of bed [HOB] elevation) for 30 minutes before the start of the feeding. Aspiration is a risk during enteral feedings in the supine position and in the left lateral position. The prone position would prevent gastric emptying and increase the risk of aspiration.
DIF: Cognitive Level: Application REF: p. 134 OBJ: 4
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
2. Which type of lubricant would the nurse use to administer a rectal suppository?
a.
Petroleum jelly
b.
Mineral oil
c.
Water soluble
d.
Anesthetic
ANS: C
Water soluble lubricants should be used with rectal suppository administration. When not available, water can be used to moisten mucosal surfaces. Petroleum based and oil based lubricants can harbor bacteria and promote infection. Unless the patient has pain in the rectal area (in which case another route of administration should be considered), anesthetic should not be required.
DIF: Cognitive Level: Knowledge REF: p. 136 OBJ: 5
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
3. Which is a characteristic of medication administration via the rectal route?
a.
Irritation of the mouth
b.
Nausea and vomiting
c.
Bypassing of the digestive enzymes
d.
Use of the first pass metabolism
ANS: C
Rectal administration bypasses the digestive enzymes because the medication is absorbed directly into the bloodstream. Rectal administration bypasses the oral cavity and does not affect the gag reflex or upset the stomach. Rectal administration bypasses first pass metabolism.
DIF: Cognitive Level: Knowledge REF: p. 124 OBJ: 5
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
4. Which medications are provided in dried, powdered form compressed into small disks?
a.
Pills
b.
Capsules
c.
Tablets
d.
Lozenges
ANS: C
Tablets are dried, powdered drugs that have been compressed into small disks. Pills are an obsolete dose form that is no longer manufactured as a result of the development of capsules and compressed tablets. Capsules are small cylindrical gelatin containers that hold dry powder or liquid medicine. Lozenges are small aromatic medicated candies, such as cough drops.
DIF: Cognitive Level: Comprehension REF: p. 125 OBJ: 1
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
5. Which action by the nurse is appropriate when administering enteric coated tablets?
a.
Administer with an antacid.
b.
Crush the tablet and mix with applesauce.
c.
Encourage the patient to drink a full glass of water.
d.
Instruct the patient to place the medication between the cheek and teeth.
ANS: C
Drinking a full glass of water ensures the medication reaches the stomach and is diluted to decrease the potential for irritation. Administering with an antacid would alter the dissolution of the enteric coated tablet because it has a coating that resists dissolution in the acidic pH of the stomach but is dissolved in the intestines. Enteric coated tablets must not be crushed and must be swallowed.
DIF: Cognitive Level: Application REF: p. 125 OBJ: 1
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
6. Which route of administration would be ordered by the health care provider if a patient is vomiting?
a.
Gastrostomy tube
b.
Intradermal
c.
Ophthalmic
d.
Rectal
ANS: D
The rectal route is a good alternative when nausea or vomiting is present. Gastrostomy is used for patients who cannot swallow or have had oral surgery; drugs administered by this route would be placed in the gastrointestinal tract and are inappropriate for the patient with vomiting. Intradermal routes are used for allergy testing. Ophthalmic medications are for use in the eye.
DIF: Cognitive Level: Application REF: p. 124 OBJ: 1
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
7. After entering the patients room to administer oral medications, which action will the nurse take first?
a.
Assist the patient to sit upright.
b.
Check the patients identification.
c.
Inform the patient about the medications.
d.
Offer the patient something to drink.
ANS: B
Checking the patients identification is the first nursing action once at the bedside. Assisting the patient to sit upright is appropriate when administering oral medications, but this is not the first thing the nurse would do. Providing information about medications is appropriate, but it is not the first thing the nurse would do. Offering the patient something to drink to facilitate swallowing of medications is appropriate, but it is not the first thing the nurse would do.
DIF: Cognitive Level: Application REF: p. 128 OBJ: 1
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
8. The nurse is preparing to administer a medication in tablet form to a patient. In administering this medication, the nurse will encourage the patient to:
a.
drink a large amount of water prior to administration so that swallowing is easier.
b.
place the medication on the front of the tongue.
c.
keep the head forward while swallowing.
d.
minimize the amount of fluid taken following medication administration.
ANS: C
The patient should be encouraged to keep the head forward while swallowing. The patient should be allowed to drink a small amount of water to moisten the mouth, so that swallowing the medication is easier. The patient should be instructed to place the medication well back on the tongue. Drinking a full glass of fluid should be encouraged to ensure that the medication reaches the stomach and is diluted to decrease the potential for irritation.
DIF: Cognitive Level: Application REF: p. 129 OBJ: 1
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
9. When assessing aspirated stomach contents, the nurse notes the color to be green with sediment. The nurse is aware that this most likely represents _____ fluid.
a.
pleural
b.
gastric
c.
intestinal
d.
tracheobronchial
ANS: B
Gastric fluid appears green with sediment or off white. Pleural fluid appears clear to straw colored. Intestinal fluid appears yellow (bile colored). Tracheobronchial fluid appears off white or tan.
DIF: Cognitive Level: Analysis REF: p. 133 OBJ: 4
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
MULTIPLE RESPONSE
10. Oral drug administration includes which principle(s)? (Select all that apply.)
a.
Dependable rate of absorption
b.
Most economical
c.
Insulin able to be administered via this route
d.
Drugs delivered directly by the oral, rectal, or nasogastric (NG) methods
e.
Dosage forms are convenient and readily available
ANS: B, E
Oral administration is the most economical, convenient, and readily available. Absorption from oral medications can vary depending on many factors. Insulin cannot be administered via the oral route. In oral drug administration, drugs are only delivered via the oral route.
DIF: Cognitive Level: Comprehension REF: p. 124 OBJ: 1
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
11. The nurse is administering an oral medication to a 90 year old patient who has difficulty swallowing pills. One of the medications to be administered is a spansule type capsule. What nursing consideration(s) should be applied in this case? (Select all that apply.)
a.
Wash hands before preparing medications and before administration.
b.
Crush medications and administer with a soft food, such as applesauce.
c.
Check the patients ID band with the MAR to ensure patient rights are followed.
d.
Have an 8 ounce glass of water available.
e.
Check with the pharmacist to see if the spansule medication comes in a liquid form.
ANS: A, C, D, E
Hands should be washed before and after medication preparation. Always check the patients identification before administering medication. Have water available to the patient when administering this medication. Giving the medication in liquid form, if available, would be much more comfortable for the patient. Spansule medications are time released and should not be crushed.
DIF: Cognitive Level: Application REF: pp. 128-129 OBJ: 1
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
12. Which receptacle(s) is/are commonly used in the hospital with pediatric oral medications? (Select all that apply.)
a.
Oral syringe
b.
Baby bottle full of formula
c.
Infant feeding nipple
d.
Teaspoon
e.
Medicine dropper
ANS: A, C, E
An oral syringe or plastic medicine cup would be most accurate. An infant feeding nipple is commonly used for pediatric patients. A medicine dropper may be used to administer medications to pediatric patients. A full bottle of formula is too large a volume in which to administer medication. A teaspoon does not minimize the risk of spilling when administering medication to a pediatric patient.
DIF: Cognitive Level: Comprehension REF: p. 127 OBJ: 3
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
13. Which data will the nurse document when administering a PRN oral pain medication to a patient? (Select all that apply.)
a.
Date, time, drug name, dosage, and route of administration
b.
Essential patient education about the drug completed
c.
Administration receptacle used
d.
Signs and symptoms of adverse drug effects
e.
Evaluation of therapeutic effectiveness
ANS: A, B, D, E
Date, time, drug name, dosage, and route of administration are included in the seven rights of medication administration. The patient should be educated about the drug being administered. The nurse should observe for adverse drug effects. Evaluating the drugs therapeutic effectiveness is important. Unless the receptacle used is unusual, it does not need to be noted.
DIF: Cognitive Level: Comprehension REF: pp. 129-130 OBJ: 1
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
14. NG medication administration includes which principle(s)? (Select all that apply.)
a.
The tube must be assessed for correct placement.
b.
All medications can be combined into one syringe.
c.
Tablets and capsules should be dissolved in water.
d.
The suction source should be immediately reconnected.
e.
Flush the tube with 30 mL of water after drug administration.
ANS: A, C, E
It is essential to verify correct placement of an NG tube. Solid medications must be crushed and dissolved in water before administration (with the exception of enteric coated tablets). Capsules should be opened and granules or powder sprinkled into 30 mL of water to dissolve (with the exception of timed released capsules). Flushing the tube serves to clear the tube and ensure that the drug has been transported to the intestine. Incompatible medications should not be combined. Suction will evacuate the medication from the patient.
DIF: Cognitive Level: Application REF: pp. 132-133 OBJ: 4
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
15. Which nursing action(s) would be appropriate when administering a disposable enema? (Select all that apply.)
a.
Position the patient on the left side.
b.
Allow the solution to flow in by gravity.
c.
Instruct the patient to hold the solution 30 minutes before defecating.
d.
Maintain the six rights of medication administration.
e.
Lubricate the rectal tube.
ANS: A, C, D, E
To facilitate flow into the large intestine, patients should be positioned on the left side. The solution should be held for 30 minutes before defecating. Enemas are medications, so the seven rights of medication administration should be followed. Lubrication of the rectal tube will facilitate insertion into the rectum. Gravity will not facilitate the administration of a small volume of enema solution administered from a bottle.
DIF: Cognitive Level: Knowledge REF: pp. 137-138 OBJ: 5
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
16. In preparing to administer medications to a patient with an NG tube, which would be appropriate to give through that route? (Select all that apply.)
a.
Liquid medication
b.
Tablets crushed and diluted in 30 mL of water
c.
Enteric coated tablets crushed and diluted in 30 mL of water
d.
Capsules emptied into 30 mL of water
e.
Timed release capsules emptied into 30 mL of water
f.
Suppositories
ANS: A, B, D
Liquid forms of medications are preferable. Tablets may be crushed and diluted in water. Capsules may be opened and the contents added to approximately 1 ounce of water. Enteric coated medications and timed release capsules should never be broken for administration. Suppositories are not given via NG route.
DIF: Cognitive Level: Application REF: pp. 132-133 OBJ: 4
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
17. An adult patient is to receive 10 mL of cough syrup at 0800. The nurse can prepare to administer this medication in a(n): (Select all that apply.)
a.
souffl cup.
b.
medicine cup.
c.
oral syringe.
d.
teaspoon.
e.
nipple.
ANS: B, C
The medicine cup is a plastic container with three scales to measure liquid medications.
An oral syringe comparable to the volume to be measured can be used for smaller volumes such as 10 mL. A souffl cup is a small paper or plastic cup used to transport solid medication forms such as a capsule or tablet to the patient to prevent contamination by handling. A teaspoon is equal to 5 mL. An infant feeding nipple with additional holes may be used for administering oral medications to infants.
DIF: Cognitive Level: Analysis REF: pp. 126-127 OBJ: 3
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
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