A nurse is caring for a 20-year-old client who has a fever and reports severe headache.
A nurse is preparing the client for a lumbar puncture. Which of the following actions should the nurse take? Select all that apply.
Provide education about the procedure.
Place the client in a lateral position with the knees drawn to the abdomen.
Ensure informed consent is obtained.
Place client NPO for 4 to 6 hr.
Obtain coagulation studies.
Assess for allergies to contrast dyes.
Administer a soapsuds enema.
Administer IV sedation as prescribed.
Correct Answer : A,B,C,D,E
A. Educating the client about the lumbar puncture procedure is crucial for informed consent and to alleviate anxiety. The nurse should explain the purpose of the procedure, what the client will experience during the procedure (such as positioning, sensation of pressure), potential risks (like headache post- procedure), and benefits (diagnostic information for the healthcare provider).
B. Positioning the client correctly is important for the success and safety of the lumbar puncture. The lateral recumbent (side lying) position with the knees drawn up towards the abdomen helps to flex the spine and widen the spaces between the vertebrae in the lumbar region. This positioning makes it easier for the healthcare provider to access the spinal canal and perform the procedure accurately.
C. Informed consent is a legal and ethical requirement before performing any invasive procedure, including a lumbar puncture. The nurse must ensure that the client (or their legally authorized representative) understands the purpose of the procedure, its risks and benefits, alternative options (if any), and gives voluntary consent without coercion.
D. NPO (nothing by mouth) status helps reduce the risk of aspiration during the procedure, especially if the client needs sedation or if complications arise requiring emergency intubation. It ensures that the client's stomach is empty, minimizing the risk of vomiting and aspiration during the procedure.
E. Coagulation studies (such as PT/INR and PTT) may be ordered to assess the client's bleeding risk before performing a lumbar puncture. This is particularly important if there are concerns about bleeding disorders or if the client is on anticoagulant medications. Normal coagulation parameters are reassuring before proceeding with an invasive procedure.
F. Contrast dye is not typically used in a routine lumbar puncture.
G. Administering a soapsuds enema is not typically necessary before a lumbar puncture unless specifically indicated by the healthcare provider. It may be used in certain cases to reduce the risk of fecal contamination during the procedure, particularly if the client is constipated.
H. IV sedation is not routinely administered during a lumbar puncture in adult clients
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hoarseness or changes in voice quality is one of the hallmark symptoms of laryngeal cancer. It occurs due to the tumor affecting the vocal cords or surrounding structures. Hoarseness is often persistent and does not resolve with voice rest or usual treatments for laryngitis.
B. Dysphagia, or difficulty swallowing, can occur in laryngeal cancer, especially if the tumor affects the structures involved in swallowing. However, dysphagia typically occurs later in the course of the disease as the tumor grows and obstructs the passage of food or liquids.
C. Weight loss can be a symptom of advanced laryngeal cancer but is less commonly reported as an early manifestation. Significant weight loss may occur as a result of difficulty eating due to dysphagia or as a generalized effect of cancer on the body.
D. Dyspnea, or difficulty breathing, is not typically an early manifestation of laryngeal cancer unless the tumor is large and obstructs the airway. It is more commonly associated with advanced disease or tumors that have spread to nearby structures.
Correct Answer is D
Explanation
A. Catheter irrigation involves flushing the catheter with a sterile solution to clear any obstruction within the tubing or catheter itself. It can help in cases where there might be clots obstructing urine flow. However, irrigating the catheter is an intervention that requires proper assessment and order from the healthcare provider.
B. This option suggests adjusting the rate of the bladder irrigant, which typically refers to the irrigation solution used during the TURP procedure to maintain catheter patency and prevent clot formation. However, this action requires assessment of the situation and potential orders from the provider.
C. Notifying the provider is often the first action the nurse should take when encountering a significant change in the client's condition or a potential complication, such as a blocked catheter. The provider needs to be informed so they can assess the situation, provide further orders, and decide on the appropriate course of action to manage the urinary retention effectively.
D. Checking the tubing for kinks or other external obstructions is a prudent initial action. Kinks or twists in the catheter tubing can prevent urine from draining properly. If a kink is identified, it can be corrected immediately, allowing urine to flow freely again.
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