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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)
- A. Don sterile gloves.
- B. Position the client supine with knees bent.
- C. Use a rectal applicator for insertion.
- D. Insert the suppository just beyond the internal sphincter.
- E. Lubricate the index finger.
Correct Answer: D,E
Rationale: The correct actions for administering a bisacodyl suppository are to insert it just beyond the internal sphincter (D) to ensure proper absorption and effectiveness. Lubricating the index finger (E) helps facilitate easier insertion and reduces discomfort for the client. Donning sterile gloves (A) is not necessary for this procedure. Positioning the client supine with knees bent (B) is not required; the Sims position is typically used. Using a rectal applicator for insertion (C) is not recommended for bisacodyl suppositories.
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A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?
- A. A client who has a small circular partial-thickness burn of the left calf.
- B. A client who has severe respiratory stridor and a deviated trachea.
- C. A client who has a splinted open fracture of the left medial malleolus.
- D. A client who has a massive head injury and is experiencing seizures.
Correct Answer: B
Rationale: The correct answer is B. The client with severe respiratory stridor and a deviated trachea should be assessed first as this indicates a compromised airway, which is a life-threatening emergency. Immediate intervention is crucial to prevent respiratory arrest. Clients with airway issues should always be the top priority in triage.
Other choices are incorrect because:
A: Small circular partial-thickness burn of the left calf is not immediately life-threatening and can be addressed after addressing more critical conditions.
C: Splinted open fracture of the left medial malleolus, while serious, does not present an immediate threat to the client's life compared to compromised airway.
D: Massive head injury and seizures are also serious, but in this scenario, the client with compromised airway takes precedence as airway issues can lead to rapid deterioration.
A nurse is teaching a client who has a new prescription for pancrelipase to aid in digestion. The nurse should inform the client to expect which of the following gastrointestinal changes?
- A. Decreased fat in stools
- B. Decreased watery stools
- C. Decreased mucus in stools
- D. Decreased black tarry stools
Correct Answer: A
Rationale: The correct answer is A: Decreased fat in stools. Pancrelipase is a pancreatic enzyme replacement therapy that helps break down fats, proteins, and carbohydrates. Therefore, the client can expect decreased fat in stools as the enzymes aid in the digestion and absorption of fats. Choice B, decreased watery stools, is incorrect as pancrelipase does not directly affect stool consistency. Choices C and D are also incorrect as pancrelipase does not directly impact mucus or the color of stools. Overall, understanding the mechanism of action of pancrelipase helps to determine the correct gastrointestinal change to expect.
A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse make?
- A. Relapse is an indication that you are not taking your medications properly.
- B. You should keep your provider’s and therapist’s number with you.
- C. Taking an additional dose of medication is appropriate as soon as signs of relapse appear.
- D. You should be aware that excessive sleeping is an early sign of relapse.
Correct Answer: B
Rationale: The correct answer is B: "You should keep your provider’s and therapist’s number with you." This is the correct statement because having easy access to contact information for healthcare providers and therapists is crucial in case of a relapse. It allows the client to seek immediate help and support when needed.
Choice A is incorrect because relapse in schizophrenia can occur even with proper medication adherence. Choice C is incorrect as taking additional medication without consulting a healthcare provider can be dangerous. Choice D is incorrect as excessive sleeping may not always be a reliable early sign of relapse.
A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?
- A. Use wool blankets on your bed.
- B. Do not adjust the oxygen flow rate.
- C. Store unused oxygen tanks horizontally.
- D. Check your oxygen equipment once each week.
Correct Answer: B
Rationale: The correct answer is B: Do not adjust the oxygen flow rate. It is essential not to adjust the oxygen flow rate as it is prescribed by a healthcare provider based on the client's condition. Incorrectly adjusting the flow rate can lead to inadequate oxygen delivery or oxygen toxicity. Choice A is incorrect as wool blankets can generate static electricity, which can be dangerous around oxygen. Choice C is incorrect because oxygen tanks should be stored vertically to prevent accidents. Choice D is incorrect as oxygen equipment should be checked daily for safety and functionality.
A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child’s appendix is perforated?
- A. Sudden decrease in abdominal pain.
- B. Absence of Rovsing’s sign.
- C. Low-grade fever.
- D. Rigid abdomen.
Correct Answer: A
Rationale: The correct answer is A: Sudden decrease in abdominal pain. A sudden decrease in abdominal pain can indicate a perforated appendix due to the release of pressure and inflammation. This sudden relief occurs when the appendix ruptures, causing the abdominal pain to subside temporarily. This is a critical sign that the appendix has perforated and requires immediate medical attention. The other choices are incorrect because: B: Absence of Rovsing’s sign is not specific to a perforated appendix. C: Low-grade fever is commonly seen in uncomplicated appendicitis and may not necessarily indicate perforation. D: A rigid abdomen is a sign of peritonitis, which can occur with a perforated appendix, but it is not as specific as the sudden decrease in pain.