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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale
Potassium iodide is used to treat hyperthyroidism and protect the thyroid gland from radiation, but it does not help lower serum potassium levels.
Choice B rationale
Lactulose is a laxative used to treat constipation and hepatic encephalopathy, but it does not affect serum potassium levels.
Choice C rationale
Sodium polystyrene sulfonate is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestines, thereby lowering serum potassium levels.
Choice D rationale
Acetylcysteine is used as a mucolytic agent and to treat acetaminophen overdose, but it does not have any effect on serum potassium levels.

A. Your body will continue producing too much insulin without medicine to counteract it. B. Your body doesn’t process glucose well. C. Your body’s hemoglobin is not binding to the sugar you consume. D. Your body’s immune system has destroyed cells in your pancreas.

Correct Answer is B

Explanation

Choice A rationale
Type 2 diabetes is characterized by insulin resistance, not the overproduction of insulin. Over time, the pancreas may produce less insulin, but the primary issue is the body’s inability to use insulin effectively.

Choice B rationale
Type 2 diabetes involves the body’s inability to process glucose properly due to insulin resistance. This leads to elevated blood glucose levels and various complications if not managed effectively.
Choice C rationale
Hemoglobin binding to sugar is related to the measurement of HbA1c, which reflects average blood glucose levels over time. It is not a cause of type 2 diabetes.
Choice D rationale
The destruction of pancreatic cells is a characteristic of type 1 diabetes, an autoimmune condition. Type 2 diabetes is primarily due to insulin resistance and is not caused by an autoimmune response.

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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.)

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