A nurse is teaching a client who is scheduled for a colposcopy tomorrow. Which of the following statements should the nurse include in the teaching?

"This procedure is routinely performed during a Pap test."

"During the procedure, a biopsy may be performed."

"Do not eat or drink after midnight tonight."

"You will have general anesthesia during this procedure."

Answer and Explanation

The Correct Answer is B

Choice A reason:

The statement "This procedure is routinely performed during a Pap test" is incorrect. A colposcopy is not routinely performed during a Pap test; it is a separate procedure that is often recommended if a Pap test shows abnormal results. The colposcopy allows for a closer examination of the cervix, vagina, and vulva to detect any signs of disease.

Choice B reason:

The statement "During the procedure, a biopsy may be performed" is correct. If the healthcare provider sees an area of concern during the colposcopy, they may take a small sample of tissue (biopsy) from the cervix or from inside the opening of the cervix.

Choice C reason:

The statement "Do not eat or drink after midnight tonight" is not necessary for a colposcopy. Unlike some surgical procedures that require general anesthesia, a colposcopy is usually done with local anesthesia, and fasting is not required.

Choice D reason:

The statement "You will have general anesthesia during this procedure" is incorrect. General anesthesia is not typically used for a colposcopy. The procedure may cause some discomfort, but it is usually performed using local anesthesia or no anesthesia at all.

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Correct Answer is C

Explanation

Choice A reason:
Keeping artificial nails trimmed is a recommended practice in healthcare settings to maintain effective hand hygiene. Long nails can harbor bacteria and make it difficult to clean hands thoroughly. However, the CDC does not provide specific guidelines on the length of artificial nails for healthcare workers.

Choice B reason:
When caring for a client with Clostridium difficile, it is recommended to wash hands with soap and water rather than using alcohol-based hand rubs. Alcohol-based hand rubs are not effective against C. difficile spores. Therefore, thorough handwashing with soap and water is necessary to remove spores.

Choice C reason:
Chlorhexidine is an antiseptic agent that provides broad-spectrum antimicrobial activity and is recommended for hand hygiene in certain situations, such as before invasive procedures or for clients who are immunosuppressed. It is effective against a wide range of bacteria, viruses, and fungi, making it a suitable choice for immunocompromised patients to reduce the risk of infection.

Choice D reason:
The use of alcohol-based hand rubs before administering eye drops is not specifically recommended. While hand hygiene is essential before any contact with a patient, there is no particular preference for alcohol-based hand rubs in this context. The primary concern is to ensure that hands are clean to prevent contamination of the eye drops or the patient's eyes.

A. A client who has type 2 diabetes mellitus with a blood glucose level of 120 mg/dL (normal range: 74-106 mg/dL). B. A client who has diabetes insipidus with an intake of 1,500 mL and an output of 1,600 mL in 24 hours. C. A client who has Graves' disease with a heart rate of 100/min and reports tremors. D. A client who has had a left-sided stroke reports a severe headache and is manifesting confusion.

Correct Answer is D

Explanation

Choice A reason:
While a blood glucose level of 120 mg/dL is slightly above the normal range, it is not typically considered an emergency for a client with type 2 diabetes mellitus. This client would require monitoring and potential adjustment of their diabetes management plan, but it does not necessitate immediate assessment.

Choice B reason:
For a client with diabetes insipidus, an intake of 1,500 mL and an output of 1,600 mL in 24 hours is within expected parameters, considering the condition's characteristic polyuria and polydipsia. This client would need ongoing monitoring to maintain fluid balance but is not the highest priority for immediate assessment.

Choice C reason:
A heart rate of 100/min and tremors in a client with Graves' disease could indicate that their condition is not well-controlled. However, these symptoms are not as acutely concerning as those of a stroke and would be addressed after more urgent needs are met.

Choice D reason:
A client who has had a left-sided stroke and reports a severe headache and confusion is exhibiting signs of a possible acute neurological change or complication, such as increased intracranial pressure or hemorrhage. This client requires immediate assessment and intervention due to the potential for rapid deterioration and life-threatening complications.

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A nurse is teaching a client who is scheduled for a colposcopy tomorrow. Which of the following statements should the nurse include in the teaching?

Nursing Test Bank

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