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:

WBC count: An elevated white blood cell (WBC) count is a common indicator of infection. The body produces more white blood cells to fight off infections, making this a key marker for identifying infections in patients with pressure ulcers. Monitoring WBC count helps in assessing the presence and severity of an infection, guiding appropriate treatment.

Choice B reason:

BUN: Blood urea nitrogen (BUN) levels are used to assess kidney function and hydration status. Elevated BUN levels can indicate dehydration or kidney dysfunction but are not specific indicators of infection. While important for overall health assessment, BUN is not directly related to detecting infections in pressure ulcers.

Choice C reason:

Potassium: Potassium levels are crucial for maintaining normal cellular function, particularly in the heart and muscles. Abnormal potassium levels can indicate issues such as kidney dysfunction or electrolyte imbalances but do not specifically indicate infection. Monitoring potassium is important for overall health but not for diagnosing infections in pressure ulcers.

A. It clearly articulates the expectations of the client. B. It demonstrates empathy towards the client. C. It sets limits on the client’s manipulative behavior. D. It uses reflection when talking with the client.

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.

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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

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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