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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason: Changing the ostomy pouch daily is not typically necessary. Most pouches can be worn comfortably for several days before needing to be changed. Frequent changes are not only unnecessary but can also irritate the skin around the stoma.

Choice B reason: Emptying the ostomy pouch when it is 2/3 full is recommended to prevent leaks and overfilling, which can lead to discomfort and potential skin irritation. It is important to monitor the fullness of the pouch and empty it regularly to maintain hygiene and comfort.

Choice C reason: Trimming the opening of the ostomy seal to be 1/2 inch wider than the stoma is incorrect. The opening should be cut to match the size of the stoma to ensure a snug fit that prevents leakage and protects the skin around the stoma.

Choice D reason: Applying lotion to the peristomal skin when changing the ostomy pouch is not advised. Lotions or creams can interfere with the adhesive of the ostomy appliance and should be avoided. The peristomal skin should be clean and dry to ensure proper adhesion of the ostomy appliance.

A. Muscle twitching B. Client report of nausea C. Serosanguineous drainage D. Client report of incisional pain

Correct Answer is A

Explanation

Choice A reason : Muscle twitching can be indicative of hypocalcemia, a common and serious complication following a complete thyroidectomy due to potential damage or removal of the parathyroid glands. Hypocalcemia requires immediate intervention to prevent more severe symptoms such as tetany or cardiac complications.

Choice B reason : While nausea is a common postoperative symptom, it is not typically as urgent as signs of hypocalcemia. However, persistent nausea should still be addressed as it can affect the client's comfort and nutritional intake.

Choice C reason : Serosanguineous drainage is expected to some extent after surgery, but if it is excessive or changes in character, it may indicate hemorrhage or infection, which would then become a priority.

Choice D reason : Incisional pain is also expected postoperatively. While pain management is important for recovery, it is not as immediately concerning as potential hypocalcemia unless the pain is severe or uncontrolled, suggesting complications.

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