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    HESI Exit II Proctored ExamQuestion 19
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    HESI Exit II Proctored Exam
    Select All That Apply

    The charge nurse observes a new nurse during the administration of two different liquid medications at once through a gastrostomy tube used for enteral feeding. The charge nurse observes the new nurse's actions. What action(s) should the charge nurse take? (Select all that apply.)

    Explanation & Rationale

    The correct answer is A, B, C, and D. Choice A reason: Flushing the gastrostomy tube with water is essential to maintain tube patency and prevent medication interactions. It should be done before and after medication administration. The typical amount of water used for flushing can range from 15 to 30 mL. Choice B reason: Administering each medication separately is a critical practice to prevent drug interactions and ensure that the full dose of each medication is delivered. It also helps in preventing the clogging of the tube. Choice C reason: Documenting all liquid volumes, including medications and water used for flushing, is important for accurate fluid intake records. This helps in maintaining fluid balance and monitoring the patient’s hydration status. Choice D reason: Checking gastric residual volume is important to assess the patient’s tolerance to enteral feeding and to prevent complications such as aspiration. Normal gastric residual volumes are generally considered to be less than 250 mL. Choice E reason: Using a plunger to administer medications through a gastrostomy tube is not always recommended. Medications should be administered slowly to prevent discomfort or harm, and the use of a plunger is not a standard practice across all healthcare settings.

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