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 D
Explanation
A. Wearing a mask is a measure of primary prevention rather than secondary prevention. It aims to prevent the transmission of the virus to others if the child is infected. However, in the context of secondary prevention, the focus is on early detection and management of the illness in the child to prevent complications.
B. This is a crucial instruction for tertiary prevention. Difficulty breathing can indicate severe illness, potentially requiring urgent medical intervention. Prompt recognition and treatment can prevent progression to respiratory failure, a serious complication of COVID-19.
C. Immunization is a form of primary prevention aimed at preventing infection before it occurs. As of now, COVID-19 vaccines are recommended for eligible school-age children to prevent infection and reduce transmission but do not directly address the management of suspected infection in a symptomatic child.
D. This is a critical step in secondary prevention. Testing for SARS-CoV-2 infection is necessary to confirm the diagnosis and initiate appropriate management and isolation measures if the child is positive. Early testing helps identify cases early and prevent further transmission in the school and community.
Correct Answer is B
Explanation
A. Notifying the laboratory is not the first action to take in this situation. While it's important to inform the laboratory about suspected transfusion reactions for further investigation and documentation, immediate patient care takes precedence to ensure the client's safety.
B. This is the correct action to take first. Stopping the infusion of blood is crucial to prevent further administration of the potentially harmful blood product. Suspecting an acute hemolytic reaction (symptoms like chills, back pain, and hypotension) necessitates immediate cessation of the transfusion to minimize complications.
C. Obtaining a urine specimen may be indicated later to assess for hemolysis and kidney function, but it is not the first action to take. The priority is to stop the transfusion and assess the client's condition to manage the suspected transfusion reaction.
D. While it's important to notify the provider promptly, stopping the transfusion (option B) is the first critical action to take in response to suspected acute transfusion reactions. The provider will need to be informed for further orders and management, but immediate cessation of the transfusion is essential to prevent worsening of the client's condition.
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.