A nurse is preparing to administer a bisacodyl suppository to a client. Which of the following actions should the nurse take? (Select all that apply)

Don sterile gloves.

Position the client supine with knees bent.

Use a rectal applicator for insertion.

Insert the suppository just beyond the internal sphincter.

Lubricate the index finger.

Answer and Explanation

Correct Answer : D,E

Choice A reason:

Don sterile gloves: While it is important to maintain cleanliness, sterile gloves are not necessary for administering a suppository. Clean, non-sterile gloves are sufficient to prevent infection and ensure hygiene.

Choice B reason:

Position the client supine with knees bent: The correct position for administering a suppository is the left lateral (Sims) position, not supine with knees bent. The left lateral position allows for easier access to the rectum and helps the suppository stay in place.

Choice C reason:

Use a rectal applicator for insertion: Suppositories are typically inserted using a gloved finger, not a rectal applicator. The gloved finger allows for better control and ensures the suppository is placed correctly.

Choice D reason:

Insert the suppository just beyond the internal sphincter: This is correct. The suppository should be inserted past the internal sphincter to ensure it stays in place and can dissolve properly. This placement helps the medication to be absorbed effectively.

Choice E reason:

Lubricate the index finger: Lubricating the index finger is essential to make the insertion process smoother and more comfortable for the client. It helps prevent trauma to the rectal mucosa and ensures the suppository is inserted easily.

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Correct Answer is ["5"]

Explanation

Step 1: Determine the total volume to be infused. = 1 liter (L)

Step 2: Convert the total volume from liters to milliliters (mL). Calculation: 1 L × 1000 mL/L = 1000 mL

Step 3: Determine the infusion rate. = 200 mL/hr

Step 4: Calculate the infusion time in hours. Calculation: 1000 mL ÷ 200 mL/hr = 5 hours

Step 5: Round the answer to the nearest whole number if necessary. = 5 hours (no rounding needed)

The nurse should expect the IV pump to infuse over 5 hours.

A. An infant who has pertussis and is receiving oxygen via nasal cannula. B. A school-age child who has diabetes mellitus and requires blood glucose monitoring. C. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions. D. A toddler who has both arms in casts and needs to be fed his breakfast.

Correct Answer is A

Explanation

Choice A reason:

An infant who has pertussis and is receiving oxygen via nasal cannula: Pertussis, also known as whooping cough, is a highly contagious respiratory disease that can be particularly severe in infants. The fact that the infant is receiving oxygen indicates respiratory distress, which is a critical condition requiring immediate attention. Infants with pertussis are at high risk for complications such as pneumonia, apnea, and respiratory failure. Therefore, this patient should be assessed first to ensure their airway and breathing are adequately supported.

Choice B reason:

A school-age child who has diabetes mellitus and requires blood glucose monitoring: While it is important to monitor blood glucose levels in children with diabetes mellitus to prevent hypo- or hyperglycemia, this condition is generally more stable and manageable compared to the acute respiratory distress seen in the infant with pertussis. Blood glucose monitoring can be scheduled and managed, making it a lower priority in this context.

Choice C reason:

An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions: Sickle cell crisis can be extremely painful and requires careful management. However, if the adolescent is ready for discharge, it indicates that their condition has stabilized. Providing discharge instructions is important but can be deferred until more critical patients are assessed.

Choice D reason:

A toddler who has both arms in casts and needs to be fed his breakfast: While this toddler requires assistance with feeding due to their casts, this situation does not pose an immediate threat to their health. Feeding can be managed after ensuring that more critical patients, such as the infant with pertussis, are stable.

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A nurse is preparing to administer a bisacodyl suppository to a client. Which of the following actions should the nurse take? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["5"]

Explanation

A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?

Correct Answer is A

Explanation

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