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,A,D,E,B

Explanation

The correct answer is choice C, A, D, E, B. Here are the rationales for each choice: Choice C rationale: Stop the infusion. The first step when an infiltration is identified is to stop the infusion. This is to prevent further infiltration of the IV fluid into the surrounding tissue. Choice A rationale: Remove the IV catheter. After stopping the infusion, the next step is to remove the IV catheter. This is to prevent any more fluid from being infused into the infiltrated area. Choice D rationale: Apply a sterile dressing. Once the IV catheter is removed, a sterile dressing should be applied to the site. This helps to prevent infection. Choice E rationale: Elevate the extremity. The affected extremity should be elevated. This helps to reduce swelling and discomfort. Choice B rationale: Apply warm or cold compresses. Finally, warm or cold compresses should be applied as per the facility’s policy. This can help to alleviate pain and reduce swelling.

A. Thrombotic stroke. B. Transient ischemic attack (TIA). C. Hemorrhagic stroke. D. Embolic stroke.

Correct Answer is C

Explanation

Choice A rationale:
A thrombotic stroke occurs when a blood clot forms in one of the arteries that supply blood to the brain. It does not typically cause a sudden, severe headache and vomiting.
Choice B rationale:
A transient ischemic attack (TIA), or “mini-stroke,” is a temporary blockage of blood flow to the brain. It does not cause a sudden, severe headache and vomiting.
Choice C rationale:
A hemorrhagic stroke occurs when a blood vessel in the brain bursts, causing bleeding into the brain. This can cause a sudden, severe headache and vomiting.
Choice D rationale:
An embolic stroke occurs when a blood clot or other debris forms away from your brain — commonly in your heart — and is swept through your bloodstream to lodge in narrower brain arteries. This type of stroke does not typically cause a sudden, severe headache and vomiting.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.).

Correct Answer is C,A,D,E,B

Explanation

Correct Answer is C

Explanation

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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?