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 D
Explanation
Choice A reason: Perform a Blind Finger Sweep
Performing a blind finger sweep is not recommended because it can push the foreign object further into the airway, making the obstruction worse. This method is only advised if the object is clearly visible and can be safely removed without causing further harm.
Choice B reason: Turn the Client to the Side
Turning the client to the side can be helpful in certain situations, such as when the client is unconscious or at risk of vomiting. However, in the case of a conscious client with a foreign body airway obstruction, this action does not directly address the obstruction and is not the first priority.
Choice C reason: Insert an Oral Airway
Inserting an oral airway is typically used to maintain an open airway in an unconscious patient who cannot maintain their own airway. For a conscious client with a foreign body obstruction, this action is not appropriate and could cause further complications.
Choice D reason: Administer the Abdominal Thrust Maneuver
Administering the abdominal thrust maneuver (also known as the Heimlich maneuver) is the recommended first action for a conscious client with a foreign body airway obstruction. This technique involves standing behind the client, placing a fist just above their navel, and delivering quick, upward thrusts to expel the foreign object. This method is effective in creating an artificial cough that can dislodge the obstruction.
Correct Answer is D
Explanation
Choice A reason: Dependent rubor
Dependent rubor is a reddish discoloration of the skin that occurs when the leg is in a dependent position (hanging down). This condition is typically associated with arterial insufficiency rather than chronic venous insufficiency. Arterial insufficiency occurs when there is inadequate blood flow through the arteries, leading to symptoms such as pain, cramping, and changes in skin color. Dependent rubor is a sign of poor arterial circulation and is not commonly seen in venous insufficiency.
Choice B reason: Thick, deformed toenails
Thick, deformed toenails can be a sign of fungal infections or other conditions affecting the nails, but they are not specifically indicative of chronic venous insufficiency. While individuals with chronic venous insufficiency may have poor circulation that can contribute to nail problems, this symptom is not a primary or common finding associated with the condition. Instead, it is more often related to other underlying health issues.
Choice C reason: Hair loss
Hair loss on the legs can occur due to various reasons, including poor circulation. However, it is more commonly associated with arterial insufficiency rather than chronic venous insufficiency. In arterial insufficiency, the reduced blood flow can lead to hair loss, shiny skin, and other changes in the lower extremities. Chronic venous insufficiency primarily affects the veins and leads to symptoms such as swelling, varicose veins, and skin changes.
Choice D reason: Edema
Edema, or swelling, is a hallmark symptom of chronic venous insufficiency. This condition occurs when the veins in the legs are unable to effectively return blood to the heart, leading to blood pooling in the lower extremities. The increased pressure in the veins causes fluid to leak into the surrounding tissues, resulting in swelling. Edema is often more pronounced at the end of the day or after prolonged periods of standing or sitting. Managing edema is a key aspect of treating chronic venous insufficiency, and it often involves the use of compression stockings, elevation of the legs, and other measures to improve venous return.
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