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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
While articulating expectations is important, the nurse’s response is more focused on addressing the client’s feelings and encouraging participation in therapy. Simply stating expectations without addressing the client’s emotions may not be as effective.
Choice B reason:
The nurse’s response demonstrates empathy by acknowledging the client’s feelings and gently guiding them towards participating in group therapy. This approach helps build trust and rapport, which are essential in therapeutic relationships, especially with clients exhibiting delusional behavior.
Choice C reason:
Setting limits on manipulative behavior is important, but in this context, the nurse’s response is more about encouraging participation and showing understanding rather than strictly setting limits.
Choice D reason:
Reflection involves mirroring the client’s feelings or statements to show understanding. While the nurse’s response does show understanding, it is not a direct example of reflection. The primary focus is on empathy and encouragement.
Correct Answer is A
Explanation
Choice A reason:
Check the drainage for glucose: Clear drainage from the nasal packing after a transsphenoidal hypophysectomy could indicate a cerebrospinal fluid (CSF) leak. CSF leaks are a serious complication that can occur after this type of surgery. Testing the drainage for glucose is a quick and effective way to determine if the fluid is CSF, as CSF contains glucose, whereas normal nasal secretions do not. Identifying a CSF leak promptly is crucial to prevent further complications such as meningitis.
Choice B reason:
Notify the client’s provider: While notifying the provider is important, it should be done after confirming the nature of the drainage. If the drainage is indeed CSF, the provider needs to be informed immediately. However, the initial step should be to check the drainage for glucose to confirm the suspicion.
Choice C reason:
Document the amount of drainage: Documentation is always important in nursing care, but it is not the immediate priority in this situation. The primary concern is to identify the nature of the drainage to address any potential complications promptly.
Choice D reason:
Obtain a culture of the drainage: Obtaining a culture can help identify any infections, but it is not the first step in this scenario. The immediate concern is to determine if the drainage is CSF, which requires checking for glucose.
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