A nurse is caring for a 20-year-old client who has a feve

A nurse is caring for a 20-year-old client who has a fever and reports severe headache.

Exhibits

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.

Answer and Explanation

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

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

A. This information highlights the importance of improving hand hygiene practices among healthcare workers. Low compliance rates indicate a need for education, reminders, and possibly changes in the healthcare facility's policies and procedures to encourage better adherence to hand hygiene protocols.
B. Hand hygiene is indeed one of the most critical measures to prevent the transmission of infections in healthcare settings. Proper hand hygiene (either washing with soap and water or using alcohol-based hand rubs) helps reduce the spread of pathogens from person to person, from surfaces to patients, and vice versa.
C. Alcohol-based hand sanitizers (gels, foams, or rubs) are effective and convenient for hand hygiene in healthcare settings. They are recommended by healthcare authorities like the CDC (Centers for Disease Control and Prevention) and WHO (World Health Organization) as they quickly reduce the number of microbes on hands when soap and water are not readily available or practical.
D. This statistic underscores the risk of healthcare-associated infections (HAIs) and the importance of preventive measures such as hand hygiene. Healthcare workers play a crucial role in reducing HAIs through proper hand hygiene practices.
E. Educating clients about hand hygiene is essential for infection prevention, especially in settings where clients can actively participate in their own care (e.g., hospitals, outpatient clinics, long-term care facilities). Clients should be encouraged to practice hand hygiene, particularly after using the restroom, before eating, and after touching surfaces that may harbor pathogens.

A. Oral hypoglycemic medications B. Insulin injections daily C. Peritoneal dialysis therapy D. Fluid restrictions

Correct Answer is A

Explanation

A. Oral hypoglycemic medications are often prescribed to lower blood glucose levels in individuals with type 2 diabetes mellitus. They work by either increasing insulin production, improving insulin sensitivity, or reducing glucose production by the liver. These medications are typically considered when lifestyle modifications alone are insufficient to achieve target blood glucose levels.
B. Insulin therapy is considered in type 2 diabetes who cannot achieve adequate glucose control with oral medications alone.
C. Peritoneal dialysis is not typically indicated as a secondary prevention measure for diabetes mellitus. Peritoneal dialysis is a treatment for end-stage renal disease (ESRD) when the kidneys can no longer function effectively.
D. Fluid restrictions may be necessary in clients with advanced kidney disease (nephropathy) resulting from diabetes. However, fluid restrictions alone do not constitute a secondary prevention action for diabetes mellitus itself.

View Question and Answer

A nurse is caring for a 20-year-old client who has a fever and reports severe headache.

Exhibits

A nurse is preparing the client for a lumbar puncture. Which of the following actions should the nurse take? Select all that apply.

View Question and Answer

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A nurse is caring for a 20-year-old client who has a fever and reports severe headache.

Exhibits

A nurse is preparing the client for a lumbar puncture. Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E"]

Explanation

Correct Answer is A

Explanation

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Resources

A nurse is caring for a 20-year-old client who has a fever and reports severe headache. Exhibits A nurse is preparing the client for a lumbar puncture. Which of the following actions should the nurse take? Select all that apply.

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Explanation

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A nurse is caring for a 20-year-old client who has a fever and reports severe headache.

Exhibits

A nurse is preparing the client for a lumbar puncture. Which of the following actions should the nurse take? Select all that apply.