A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take?
Instruct the client to expect tingling in their extremities.
Measure blood glucose every 2 hours.
Limit the client's fluid intake.
Instruct the client to lie flat.
The Correct Answer is D
Choice A reason: Instructing the client to expect tingling in their extremities is not a standard post-lumbar puncture care instruction. Tingling may be a sign of nerve irritation or damage, which is not an expected outcome and should be reported if it occurs.
Choice B reason: Measuring blood glucose every 2 hours is not related to post-lumbar puncture care unless the client has a specific condition that requires such monitoring. Post-lumbar puncture care focuses on preventing complications such as headaches and monitoring for signs of infection or bleeding.
Choice C reason: Limiting the client's fluid intake is not advised following a lumbar puncture. In fact, increasing fluid intake can help prevent the occurrence of post-lumbar puncture headaches, which are a common complication. Adequate hydration helps replenish cerebrospinal fluid and reduce headache severity.
Choice D reason: Instructing the client to lie flat is the correct action. After a lumbar puncture, it is recommended that the client lies flat for several hours to prevent the leakage of cerebrospinal fluid from the puncture site, which can lead to a spinal headache. Lying flat helps maintain normal cerebrospinal fluid pressure and reduces the risk of headache.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Clearing items from the client's surrounding area is important, but it is not the first action a nurse should take. The priority is to prevent injury to the client, and while removing potential hazards is part of this, it comes after ensuring the client's immediate safety.
Choice B reason: Loosening restrictive clothing can help the client breathe more easily and prevent further injury. However, this is not the first step in seizure first aid. The initial focus should be on preventing injury by controlling the client's fall.
Choice C reason: Lowering the client to the floor is the first and most critical action to take. This prevents a fall that could result in serious injury. Once on the floor, the client should be turned gently onto one side to help maintain an open airway and allow any fluids to drain, which can help prevent aspiration.
Choice D reason: Obtaining the client's vital signs is a secondary action after the seizure has ended. During a seizure, the primary concern is the client's immediate safety, which includes preventing injury and maintaining an open airway.
Correct Answer is D
Explanation
Choice A reason: While it is generally advised to avoid taking blood pressure readings from an arm with a PICC line to prevent complications, if the right arm cannot be used, as may be the case with the other clients listed, the nurse may have to use the left arm with extreme caution, ensuring not to disrupt the PICC line.
Choice B reason: Bell's palsy affects facial nerves and does not typically impact the measurement of blood pressure. Therefore, there is no contraindication to using the left arm for a blood pressure reading in a client with left-sided Bell's palsy.
Choice C reason: A client with right-sided weakness due to Parkinson's disease can have their blood pressure taken on the left side if the right side is too weak to provide an accurate reading or if using the right side would cause discomfort to the client.
Choice D reason: For a client with a right upper extremity arteriovenous fistula, typically created for dialysis access, blood pressure measurements should not be taken on that arm to avoid damaging the fistula. Therefore, the left arm should be used for blood pressure readings in this case.
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