A nurse is preparing a client for a colposcopy following an abnormal Papinicolaou (Pap) test. Which of the following actions should the nurse take?
Place the client in the Sims' position.
Insert a tampon following the procedure.
Instruct the client to avoid sexual intercourse until the cervix is healed.
Reinforce teaching that the procedure involves dilation of the cervix.
The Correct Answer is C
Choice A: This is incorrect because placing the client in the Sims' position is not necessary for a colposcopy. The nurse should place the client in the lithotomy position, which allows better visualization of the cervix and vagina.
Choice B: This is incorrect because inserting a tampon following the procedure can interfere with healing and increase the risk of infection. The nurse should instruct the client to avoid using tampons, douches, or vaginal creams for at least a week after the procedure.
Choice C: This is correct because instructing the client to avoid sexual intercourse until the cervix is healed can prevent bleeding, infection, and trauma to the cervix. The nurse should advise the client to abstain from sexual activity for at least a week or until advised by the provider.
Choice D: This is incorrect because reinforcing teaching that the procedure involves dilation of the cervix can cause anxiety and discomfort for the client. The nurse should explain that the procedure does not require dilation of the cervix, but rather involves applying a speculum and using a microscope to examine the cervix and take tissue samples if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is d,b,e,a,c
Explanation
The sequence the nurse should use to administer the medication using the Z-track technique is:
- Step 1: Put on gloves and cleanse the site with an antiseptic swab.
- Step 2: Use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 in) laterally.
- Step 3: Insert the needle into the muscle.
- Step 4: Aspirate by pulling back on the plunger and inject the medication.
- Step 5: Remove the needle and release the tissue.
Correct Answer is A
Explanation
Choice A reason: The nurse should contact the provider to clarify the prescription because applying heat to an area with impaired sensation can cause burns or tissue damage. The nurse should also educate the client about the risks of using heat therapy and alternative methods to relieve pain.
Choice B reason: The Semmes Weinstein monofilament test is used to assess the sensation of light touch in clients with peripheral neuropathy. The nurse should perform this test before applying any intervention that could affect the skin integrity, such as heat, cold, or compression.
Choice C reason: Observing the skin 10 min after the start of treatment is not sufficient to prevent complications from heat therapy. The nurse should monitor the skin continuously and check for signs of redness, blisters, or burns.
Choice D reason: Applying the heating pad as prescribed by the provider is not appropriate for a client with diabetic neuropathy of the lower extremities. Heat can increase blood flow and inflammation in the affected area, which can worsen the condition and increase the risk of infection.
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