A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)
Monitor the puncture site for hematoma.
Elevate the client’s head of bed.
Insert a urinary catheter.
Encourage fluid intake.
Apply a cervical collar to the client.
Correct Answer : A,D
Choice A rationale
Monitoring the puncture site for hematoma is crucial because a hematoma can indicate bleeding at the puncture site, which can lead to complications such as infection or nerve damage. Hematomas can also cause increased intracranial pressure, which can be dangerous for the patient. Therefore, it is essential to monitor the site closely to ensure that any signs of bleeding are detected early and managed appropriately.
Choice B rationale
Elevating the client’s head of bed is incorrect because it can increase the risk of cerebrospinal fluid (CSF) leakage from the puncture site. After a lumbar puncture, it is recommended to keep the patient in a flat position for several hours to reduce the risk of post-lumbar puncture headache and to allow the puncture site to heal properly. Elevating the head of the bed too soon can disrupt this process and lead to complications.
Choice C rationale
Inserting a urinary catheter is incorrect because it is not a standard procedure following a lumbar puncture. The primary focus after a lumbar puncture is to monitor for complications related to the procedure itself, such as bleeding, infection, or CSF leakage. Inserting a urinary catheter is not necessary unless there is a specific indication for it, such as urinary retention or other urological issues.
Choice D rationale
Encouraging fluid intake is correct because it helps to replenish the CSF that was removed during the lumbar puncture. Increased fluid intake can also help to reduce the risk of post- lumbar puncture headache, which is a common complication. Hydration is important for overall recovery and helps to maintain normal bodily functions.
Choice E rationale
Applying a cervical collar to the client is incorrect because it is not related to the care of a lumbar puncture site. A cervical collar is typically used for patients with neck injuries or conditions affecting the cervical spine. It has no role in the management of a lumbar puncture site and would not provide any benefit in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
An indurated area of 4 millimeters is not considered a positive result for tuberculin skin testing. The size of induration considered positive varies based on the individual’s risk factors and health status.
Choice B rationale
The injection site for a tuberculin skin test should be evaluated between 48 and 72 hours after administration, not within 24 hours. Evaluating it too early may not provide accurate results.
Choice C rationale
A positive result in a tuberculin skin test indicates that the person has been infected with TB bacteria, but it does not necessarily mean they have active TB disease. Further tests are needed to determine if the disease is active.
Choice D rationale
A previous negative result does not preclude the administration of a new tuberculin skin test. Individuals can be retested if there is a new risk of exposure or if it is required for medical or occupational reasons.
Correct Answer is C
Explanation
Choice A rationale
A high-purine diet can lead to the formation of uric acid stones, which are a type of kidney stone. However, it is not the most common risk factor for urolithiasis. Urolithiasis is more commonly associated with factors such as dehydration, which leads to concentrated urine and promotes stone formation.
Choice B rationale
Female gender is not a significant risk factor for urolithiasis. In fact, men are more likely to develop kidney stones than women. The higher incidence in men is thought to be related to differences in diet, fluid intake, and urinary tract anatomy.
Choice C rationale
Dehydration is a major risk factor for urolithiasis. When the body is dehydrated, urine becomes more concentrated, which increases the likelihood of stone formation. Adequate hydration helps to dilute the urine and reduce the risk of stone formation.
Choice D rationale
Family history is a known risk factor for urolithiasis. Individuals with a family history of kidney stones are more likely to develop them due to genetic predispositions that affect factors such as urine composition and kidney function.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.