A nurse is caring for a client who is undergoing a lumbar puncture.

Which of the following is the priority action for the nurse to take to maintain privacy for the client?

Pull the curtains around the client's bed.

Ask family members to leave the room.

Use sterile drapes to cover the client.

Close the door to the client's room.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Pulling the curtains around the client’s bed ensures privacy during the procedure.
Choice B rationale:
Asking family members to leave the room might be necessary, but it’s not the priority action.
Choice C rationale:
Using sterile drapes to cover the client is important for maintaining sterility, not privacy.
Choice D rationale:
Closing the door to the client’s room can provide privacy, but pulling the curtains around the bed is a more immediate action.

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Correct Answer is C

Explanation

Choice A rationale:
Determining if the client needs to continue IV therapy is important, but it is not the first action the nurse should take. The nurse should first address the immediate problem, which is the irritated IV site.
Choice B rationale:
Initiating a new IV line in the other extremity is necessary, but not the first action. The nurse should first discontinue the existing IV line to prevent further irritation or infection.
Choice C rationale:
The nurse should first discontinue the existing IV line. This is because the symptoms indicate that the client might have developed phlebitis, an inflammation of the vein, which requires immediate discontinuation of the IV line.
Choice D rationale:
Applying a hot pack to the irritated site can help reduce inflammation and discomfort, but it is not the first action. The nurse should first discontinue the IV line to prevent further complications.

A. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. B. Notify the surgeon if white drainage develops on the eyelids. C. Sleep on the abdomen to facilitate wound healing. D. Bend at the waist to pick objects up from the floor.

Correct Answer is A

Explanation

Choice A rationale:
Lifting heavy objects can increase intraocular pressure, which should be avoided after cataract surgery.
Choice B rationale:
Any drainage should be reported, not just white.
Choice C rationale:
Sleeping position won’t necessarily affect wound healing in this case.
Choice D rationale:
Bending at the waist can increase intraocular pressure, which should be avoided.

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A nurse is caring for a client who is undergoing a lumbar puncture. Which of the following is the priority action for the nurse to take to maintain privacy for the client?

Nursing Test Bank

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A nurse is caring for a client who is undergoing a lumbar puncture.

Which of the following is the priority action for the nurse to take to maintain privacy for the client?