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Difficulty: MediumPharmacological Therapies

A practical nurse is assigned to care for an adult client who has dysphagia following a recent stroke. The client receives continuous enteral nutrition via an established gastrostomy tube. The client's morning vital signs include a blood pressure of 118/76 mm Hg, heart rate of 78 beats/minute, and respiratory rate of 16 breaths/minute. The client has no known drug allergies. The practical nurse is preparing to administer a scheduled dose of a liquid multivitamin via the gastrostomy tube. Which of the following actions should the practical nurse take to ensure safe medication administration?

  1. Flush the gastrostomy tube with 15 to 30 milliliters of water before and after administering the medication.Answer
  2. B
    Verify the client's identity by checking the room number on the door and asking the client to nod.
  3. C
    Estimate the milliliter equivalent of a prescribed tablespoon dosage without using a calibrated measuring device.
  4. D
    Agree to administer a concurrent intravenous push analgesic for the client as delegated by the registered nurse.

Answer

The correct action is to flush the gastrostomy tube with 15 to 30 milliliters of water before and after administering the medication.
Administering medications via an enteral route, such as a gastrostomy tube, requires the nurse to maintain tube patency and ensure complete drug delivery. Flushing the tube with 15 to 30 milliliters of water before administration confirms the tube is clear and functioning. Flushing again with 15 to 30 milliliters of water after administration clears the tube of any residual medication, preventing blockages and ensuring the client receives the entire prescribed dose.

Step-by-Step Solution

1
Analyze the clinical scenario and the prescribed route of medication administration.
The medication is to be administered via a gastrostomy tube to a clinically stable client.
Identifying the administration route is essential to determine the specific procedural safety checks required.
2
Evaluate the principles of safe enteral medication administration.
Best practice guidelines dictate flushing the enteral tube with 15 to 30 mL of water before and after giving medications.
Flushing prevents tube occlusion, verifies patency, and ensures the entire medication dose reaches the stomach.
3
Review the distractors for violations of safe nursing practice.
Using a room number for identification, estimating liquid dosages, and accepting intravenous push assignments all violate practical nurse scope of practice and safety standards.
Recognizing and avoiding unsafe practices reinforces the boundaries of the practical nurse role and protects client safety.

Key Concept

Safe Medication Administration via Enteral Tubes
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Topics

Pharmacological Therapies

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