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 A
Explanation
Choice a: Placing the client in high-Fowler's position is the first action that the nurse should take because it can improve lung expansion and oxygenation, which are priority needs for a client who has a pulmonary embolism and is experiencing dyspnea.
Choice b is not correct because administering heparin to the client is not the first action that the nurse should take, but rather a subsequent action after ensuring adequate oxygenation. Heparin can prevent further clot formation and reduce the risk of complications, but it does not dissolve existing clots or improve respiratory status.
Choice c is not correct because encouraging the client to cough and deep breathe is not the first action that the nurse should take, but rather an ongoing intervention that can help mobilize secretions and prevent atelectasis. However, it may not be effective or feasible for a client who has severe dyspnea.
Choice d is not correct because obtaining the client's vital signs is not the first action that the nurse should take, but rather an assessment that can provide baseline data and monitor changes in condition. However, it does not address the immediate problem of impaired gas exchange or relieve dyspnea.
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.
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