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 A

Explanation

Choice A reason: Explaining the procedure, risks, and benefits

Explaining the surgical procedure, including its risks and benefits, is primarily the responsibility of the surgeon. This is because the surgeon has the detailed knowledge and expertise regarding the specific procedure and can provide comprehensive information to the patient. The nurse’s role in this context is to support the patient by clarifying any information provided by the surgeon and ensuring that the patient understands the instructions. Nurses can also address any immediate concerns or questions the patient might have, but the detailed explanation of the procedure itself is outside their scope of practice.

Choice B reason: Reviewing preoperative instructions

Reviewing preoperative instructions is within the nurse’s responsibilities. Nurses play a crucial role in ensuring that patients understand and follow preoperative instructions, which may include fasting guidelines, medication adjustments, and other preparatory steps. This helps to minimize surgical risks and ensures that the patient is adequately prepared for the procedure. By reviewing these instructions, nurses help to reinforce the information provided by the surgical team and ensure patient compliance.

Choice C reason: Obtaining test results

Obtaining and reviewing test results is also within the nurse’s scope of practice. Nurses are responsible for ensuring that all necessary preoperative tests have been completed and that the results are available for the surgical team. This includes coordinating with the laboratory and other departments to obtain timely results and reviewing them to identify any potential issues that need to be addressed before surgery. This step is critical in ensuring patient safety and readiness for the procedure.

Choice D reason: Ensuring that a signed surgical consent form was completed

Ensuring that a signed surgical consent form is completed is a shared responsibility between the nurse and the surgeon. While the surgeon is responsible for obtaining informed consent by explaining the procedure, risks, and benefits, the nurse’s role is to verify that the consent form has been signed and documented appropriately. This verification process is crucial to ensure that the patient has given informed consent before proceeding with the surgery.

Choice E reason: Assessing the current health status of the client

Assessing the current health status of the client is a fundamental responsibility of the nurse. This involves conducting a thorough health assessment, including taking vital signs, reviewing the patient’s medical history, and identifying any potential risks or concerns that may affect the surgery. This assessment helps to establish a baseline for the patient’s condition and ensures that any necessary precautions are taken to promote a safe surgical outcome.

A. Airborne B. Contact C. Protective D. Droplet

Correct Answer is D

Explanation

Choice A reason: Airborne

Airborne precautions are used for diseases that are transmitted through tiny airborne particles that can remain suspended in the air and be inhaled by others. Examples of diseases requiring airborne precautions include tuberculosis, measles, and chickenpox. These diseases can spread over long distances and through ventilation systems. Pertussis, however, is not transmitted via airborne particles but rather through larger respiratory droplets.

Choice B reason: Contact

Contact precautions are used for infections that are spread by direct or indirect contact with the patient or the patient’s environment. This includes infections like methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile (C. diff). While contact precautions are important for preventing the spread of certain infections, pertussis is primarily spread through respiratory droplets, making droplet precautions more appropriate.

Choice C reason: Protective

Protective precautions, also known as reverse isolation, are used to protect immunocompromised patients from potential infections. This type of precaution is not intended to prevent the spread of infections from the patient to others but rather to protect the patient from external sources of infection. Examples include patients undergoing chemotherapy or those with severe immunodeficiency. Pertussis does not require protective precautions as it is not about protecting the patient from others.

Choice D reason: Droplet

Droplet precautions are the appropriate transmission-based precautions for pertussis. Pertussis, also known as whooping cough, is spread through respiratory droplets that are produced when an infected person coughs, sneezes, or talks. These droplets can travel short distances and can infect others who are in close proximity. Droplet precautions include wearing a mask when within 3 feet of the patient, placing the patient in a private room if possible, and ensuring that the patient wears a mask if they need to be transported.

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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

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