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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Administering oxygen at 2 L/min is appropriate for clients with emphysema who have hypoxemia. Oxygen therapy should be titrated based on the client's oxygen saturation levels to avoid suppressing the respiratory drive.
Choice B reason: The use of incentive spirometry is beneficial for clients with emphysema as it encourages deep breathing and helps prevent atelectasis. It is an appropriate intervention to include in the plan of care.
Choice C reason: Breathing exercises for clients with emphysema typically focus on prolonging the exhalation phase, not the inhalation phase, to improve airway clearance and reduce the work of breathing.
Choice D reason: Limiting fluid intake is not generally recommended for clients with emphysema unless there are specific contraindications. Adequate hydration can help thin secretions and improve mucus clearance.
Correct Answer is C
Explanation
Choice A reason: Anticonvulsants are medications used to prevent seizures. While seizures can occur after a stroke, anticonvulsants are not routinely prescribed unless the patient has a history of seizures or has experienced seizures post-stroke. Therefore, anticonvulsants would not be the standard pharmacologic therapy for all patients being discharged after an ischemic stroke.
Choice B reason: Diuretics are used to remove excess fluid from the body and are commonly prescribed for conditions such as heart failure or high blood pressure. They are not typically used as a standard treatment for ischemic stroke unless the patient has a specific condition that requires fluid management.
Choice C reason: Antithrombotic agents, such as aspirin or clopidogrel, are commonly prescribed to patients after an ischemic stroke to prevent further clot formation and reduce the risk of recurrent strokes. These medications work by inhibiting platelet aggregation and are a key part of secondary prevention in stroke management.
Choice D reason: Opioid analgesics are strong painkillers that are used to treat severe pain. They are not typically prescribed upon discharge for ischemic stroke patients unless there is a specific indication for pain management that cannot be managed with other medications.
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