Nokea
A nurse is preparing to administer a rectal suppository to a client. What action should the nurse take?
- A. Encourage the client to hold their breath as long as possible.
- B. Insert the suppository just past the anal sphincter.
- C. Lubricate the suppository and insert it 1.5 cm (0.6 in) into the rectum.
- D. Place the client in a Sims' position before inserting the suppository.
Correct Answer: D
Rationale: The correct action the nurse should take when administering a rectal suppository is to place the client in a Sims' position. This position helps facilitate the proper administration of the suppository by allowing better access to the rectum. Encouraging the client to hold their breath as long as possible (Choice A) is unnecessary and not related to the administration of a rectal suppository. Inserting the suppository just past the anal sphincter (Choice B) is incorrect as it may not reach the rectum where it needs to be placed. Lubricating the suppository and inserting it 1.5 cm into the rectum (Choice C) is incorrect as the suppository needs to be inserted deeper into the rectum for proper absorption.
You may also like to solve these questions
A healthcare professional is preparing to administer ceftriaxone IM to a client. Which of the following actions should the healthcare professional take?
- A. Administer the medication using a tuberculin syringe
- B. Administer the medication at a 45-degree angle
- C. Use the dorsogluteal muscle for injection
- D. Aspirate for blood return before injecting the medication
Correct Answer: D
Rationale: Correct Answer: When administering intramuscular injections like ceftriaxone, it is essential to aspirate for blood return before injecting the medication to ensure that the needle is not in a blood vessel. Choices A and B are incorrect because ceftriaxone is typically administered using a syringe appropriate for IM injections (not a tuberculin syringe) and injected at a 90-degree angle rather than 45 degrees. Choice C is incorrect because the dorsogluteal site is no longer recommended for IM injections due to potential injury to the sciatic nerve and other structures.
A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take first?
- A. Check the client's identification band
- B. Verify the provider's prescription
- C. Prime the IV tubing with 0.9% sodium chloride
- D. Obtain the client's vital signs
Correct Answer: A
Rationale: The correct first action for the nurse to take when preparing to administer a unit of packed RBCs is to check the client's identification band. This step is crucial to ensure that the correct blood is administered to the right client, preventing any errors or adverse reactions. Verifying the provider's prescription, priming the IV tubing, and obtaining the client's vital signs are important steps in the process but should follow the initial identification check to prioritize patient safety.
A nurse is caring for a client who is receiving TPN. Which of the following actions should the nurse take to prevent infection?
- A. Change the TPN tubing every 72 hours.
- B. Monitor the client's blood glucose every 4 hours.
- C. Monitor the client's urine output every 8 hours.
- D. Use sterile technique when changing the central line dressing.
Correct Answer: D
Rationale: The correct answer is D: 'Use sterile technique when changing the central line dressing.' When caring for a client receiving TPN, it is crucial to maintain aseptic technique to prevent infections. Changing the central line dressing with sterile technique helps reduce the risk of introducing pathogens into the client's system. Choices A, B, and C are incorrect because changing the TPN tubing every 72 hours, monitoring blood glucose, and monitoring urine output are important aspects of care but are not directly related to preventing infection in clients receiving TPN.
A nurse is caring for a client who is receiving enteral nutrition through a nasogastric tube. Which of the following actions should the nurse take?
- A. Flush the tube with 30 mL of sterile water before each feeding
- B. Administer the feeding using a large-bore syringe
- C. Keep the head of the bed elevated to 15 degrees
- D. Replace the feeding bag every 24 hours
Correct Answer: A
Rationale: The correct action for the nurse to take is to flush the tube with 30 mL of sterile water before each feeding. This helps maintain tube patency and prevents clogs. Choice B is incorrect because enteral feedings should be administered using a gravity drip method or a pump, not through a large-bore syringe. Choice C is incorrect because the head of the bed should be elevated to at least 30 degrees to reduce the risk of aspiration. Choice D is incorrect because the feeding bag should be replaced every 24 hours to prevent bacterial contamination.
A nurse is caring for a client who has osteoarthritis. Which of the following actions should the nurse take?
- A. Apply heat to inflamed joints
- B. Provide passive range-of-motion exercises
- C. Encourage prolonged use of NSAIDs
- D. Apply cold packs to the joints
Correct Answer: A
Rationale: Corrected Rationale: Applying heat to inflamed joints can help relieve pain in clients with osteoarthritis. Heat therapy can help improve blood circulation, relax muscles, and reduce stiffness. Choice B, providing passive range-of-motion exercises, may be beneficial for joint mobility but is not the first-line intervention for pain relief in osteoarthritis. Choice C, encouraging prolonged use of NSAIDs, should be done cautiously due to potential side effects and should be guided by a healthcare provider. Choice D, applying cold packs to the joints, is not recommended for osteoarthritis as cold therapy can worsen stiffness and discomfort in this condition.