Nokea
The nurse is about to give a rectal suppository to a patient. Which technique would facilitate the administration and absorption of the rectal suppository?
- A. Having the patient lie on the right side, unless contraindicated
- B. Having the patient hold his or her breath during insertion of the medication
- C. Lubricating the suppository with a small amount of petroleum-based lubricant before insertion
- D. Encouraging the patient to lie on the left side for 15 to 20 minutes after insertion
Correct Answer: D
Rationale: Positioning the patient on the left side and using a water-soluble lubricant facilitates insertion and absorption of a rectal suppository. The patient should remain on the left side for 15-20 minutes. Petroleum-based lubricants are not used, and breath-holding is not necessary.
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A patient is to receive hydromorphone 1.5 mg IV push now. The medication comes in a prefilled syringe, 2 mg/mL. Identify how many milliliters the nurse will administer for this dose.
Correct Answer: 0.75 mL
Rationale: To calculate: 2 mg/1 mL = 1.5 mg/x mL. Cross-multiply: (2 * x) = (1 * 1.5); 2x = 1.5; x = 1.5/2 = 0.75 mL.
When adding medications to a bag of intravenous (IV) fluid, the nurse will use which method to mix the solution?
- A. Shaking the bag or bottle vigorously
- B. Turning the bag or bottle gently from side to side
- C. Inverting the bag or bottle one time after injecting the medication
- D. Allowing the IV solution to stand for 10 minutes to enhance even distribution of medication
Correct Answer: B
Rationale: Gently turning the IV bag or bottle from side to side ensures even mixing of the medication without causing bubbles or degradation. The other methods are insufficient or inappropriate.
The nurse is administering an IV push medication through an IV lock. After injecting the medication, which action will be taken next?
- A. Flushing the lock
- B. Regulating the IV flow
- C. Clamping the tubing for 10 minutes
- D. Holding the patient's arm up to improve blood flow
Correct Answer: A
Rationale: Flushing the IV lock with saline or heparin (per facility policy) after administering an IV push medication ensures the medication is cleared from the lock and prevents clotting. The other actions are not appropriate.
After administering an intradermal (ID) injection for a skin test, the nurse notices a small bleb at the injection site. Which of these is the best action for the nurse to take at this time?
- A. Apply heat.
- B. Massage the area.
- C. Do nothing.
- D. Report the bleb to the physician.
Correct Answer: C
Rationale: A small bleb is an expected outcome after an intradermal injection for skin testing, indicating proper administration. No further action is needed.
When administering nasal spray, which instruction by the nurse is appropriate?
- A. You will need to blow your nose before I give this medication.'
- B. You will need to blow your nose after I give this medication.'
- C. When I give this medication, you will need to hold your breath.'
- D. You need to sit up for 5 minutes after you receive the nasal spray.'
Correct Answer: A
Rationale: Clearing the nasal passages by blowing the nose before administering nasal spray ensures effective delivery. Blowing afterward removes the medication, holding breath is unnecessary, and the patient should remain supine, not sit up.