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A nurse is preparing a client for a colposcopy following an abnormal Papanicolaou (Pap) test. Which of the following actions should the nurse take?
- A. Insert a tampon following the procedure.
- B. Reinforce teaching that the procedure involves dilation of the cervix.
- C. Place the client in the Sims' position.
- D. Instruct the client to avoid sexual intercourse until the cervix is healed.
Correct Answer: D
Rationale: A colposcopy is a diagnostic procedure to examine the cervix, vagina, and vulva after an abnormal Pap test, typically involving a speculum and mild discomfort but no cervical dilation. Option A is incorrect because inserting a tampon post-procedure could introduce infection or interfere with healing, especially if biopsies were taken. Option B is wrong as colposcopy does not require cervical dilation; it's a visual inspection, unlike procedures like a D&C. Option C, Sims' position (lateral with knees bent), is not standard lithotomy position is used instead for pelvic access. Option D is correct because advising the client to avoid sexual intercourse until healing prevents irritation, infection, or disruption of any biopsy sites, aligning with post-procedure care guidelines. This instruction supports recovery and ensures accurate follow-up results, making it the most appropriate nursing action.
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A nurse is collecting data from a client who is perimenopausal. Which of the following findings is the priority for the nurse to report to the provider?
- A. Difficulty sleeping
- B. Hot flashes
- C. Vaginal dryness
- D. Urinary frequency
Correct Answer: D
Rationale: Perimenopause brings hormonal shifts, but urinary frequency stands out it may signal a UTI, bladder issue, or pelvic pathology, requiring urgent evaluation over typical symptoms. Difficulty sleeping and hot flashes stem from estrogen fluctuations, common and manageable with lifestyle changes. Vaginal dryness, also hormonal, responds to lubricants or estrogen therapy, not immediate concern. Frequency, however, risks infection or renal complications older women often present atypically (e.g., confusion), per geriatric guidelines. Using ABCs, elimination issues outrank comfort, driving prompt reporting for diagnostics (e.g., urinalysis), preventing progression, making it the priority finding.
A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?
- A. Have the client wear a surgical mask during transport.
- B. Wear an N95 mask while providing care to the client.
- C. Administer an influenza immunization to the client.
- D. Place the client in a negative airflow room.
Correct Answer: A
Rationale: A surgical mask during transport prevents droplet spread of influenza. An N95 and negative airflow are for airborne diseases, and immunization isn't given during active infection.
A home health nurse is reinforcing teaching with an older adult client about safety precautions to take in the home. Which of the following instructions should the nurse include?
- A. Place white tape on the edges of stairs.
- B. Place area rugs on wooden floors.
- C. Run wires and cords under carpeting.
- D. Have the furnace inspected every 2 years.
Correct Answer: A
Rationale: White tape on stair edges improves visibility, reducing fall risk in older adults. Rugs and hidden cords are trip hazards, and furnace checks should be annual, not biennial.
A nurse is contributing to the plan of care for a client who has HIV. Which of the following interventions should the nurse plan to include?
- A. Provide a diet of pureed foods.
- B. Encourage fluids with meals.
- C. Offer small, frequent meals.
- D. Suggest fresh fruits and vegetables.
Correct Answer: C
Rationale: Clients with HIV often experience nutritional challenges due to symptoms like nausea, fatigue, or opportunistic infections, necessitating a tailored dietary plan. Option A, pureed foods, is suited for swallowing difficulties, not a general HIV need, so it's inappropriate. Option B, encouraging fluids with meals, may dilute gastric juices and worsen digestion or appetite, countering nutritional goals. Option C is correct small, frequent meals help maintain energy, combat weight loss, and accommodate reduced appetite or early satiety common in HIV, supporting immune function and medication tolerance. Option D, fresh fruits and vegetables, sounds healthy but risks infection (e.g., from unwashed produce) in immunocompromised clients, requiring caution or cooking instead. Small, frequent meals align with evidence-based HIV care, optimizing calorie intake and nutrient absorption without overwhelming the digestive system, making it the most effective and safe intervention for this population.
A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan?
- A. Ask the provider for a prescription for a pureed diet.
- B. Have an assistive personnel feed the client.
- C. Obtain a referral for physical therapy.
- D. Apply foam handles to the client's eating utensils.
Correct Answer: D
Rationale: Chronic arthritis often impairs hand dexterity and grip strength, making self-feeding challenging. Option A, a pureed diet, addresses swallowing issues, not arthritis-related difficulties with utensils, so it's irrelevant here. Option B, having assistive personnel feed the client, undermines independence and dignity without addressing the root issue of utensil handling. Option C, physical therapy, may improve joint function long-term but doesn't provide immediate help for eating. Option D is correct applying foam handles increases utensil girth, improving grip for arthritic hands, promoting self-feeding and autonomy. This intervention directly tackles the physical limitation caused by arthritis, aligning with nursing goals of enhancing quality of life and independence. It's practical, cost-effective, and can be implemented quickly, offering immediate relief while other therapies (like PT) work in the background. Evidence supports adaptive equipment as a first-line strategy for arthritis patients struggling with daily activities, making this the most appropriate and empowering choice.