A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure?

Fluid overload.

Diarrhea.

Headache.

Difficulty voiding.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Headache.

Choice A rationale:

Fluid overload is not a potential adverse effect of a lumbar puncture. A lumbar puncture involves the removal of cerebrospinal fluid (CSF) from the spinal canal, which wouldn't lead to fluid overload. This choice is not relevant to the procedure.

Choice B rationale:

Diarrhea is not a common adverse effect of a lumbar puncture. The procedure involves accessing the spinal canal and collecting CSF, which is not directly connected to the gastrointestinal system. Diarrhea is unrelated to the procedure.

Choice C rationale:

Headache is a potential adverse effect of a lumbar puncture. This is caused by the leakage of cerebrospinal fluid (CSF) through the puncture site, leading to a decrease in CSF pressure. This drop in pressure can cause a headache, particularly when the client sits or stands up. The headache is often described as severe and may be accompanied by neck pain and sensitivity to light. It usually resolves within a few days but can be managed with pain relief medications and plenty of fluids.

Choice D rationale:

Difficulty voiding is not a common adverse effect of a lumbar puncture. The procedure involves the lower back and spinal canal, and it doesn't directly affect the urinary system. This choice is unrelated to the procedure and its potential complications.

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Correct Answer is C

Explanation

The correct answer is choice C: "I should remove constrictive clothing prior to measuring my blood pressure."

Choice A rationale:

"I will wait 15 minutes after drinking coffee to measure my blood pressure." Caffeine intake can temporarily elevate blood pressure, so waiting 15 minutes after drinking coffee is a good practice. However, this is not the most relevant instruction to ensure accurate blood pressure measurement.

Choice B rationale:

"I will measure my blood pressure while my arm is elevated above my heart." Measuring blood pressure with the arm elevated above the heart can result in artificially low readings. The arm should be supported at heart level for accurate results. Therefore, this statement is incorrect.

Choice C rationale:

"I should remove constrictive clothing prior to measuring my blood pressure." This is the correct choice. Constrictive clothing can impact blood flow and give inaccurate readings. Removing tight clothing ensures the blood pressure cuff can be appropriately placed and that the measurements are reliable.

Choice D rationale:

"I should measure my blood pressure immediately after eating breakfast." Blood pressure can be affected by food intake, so it's recommended to wait at least 30 minutes after eating before measuring blood pressure. This choice is not accurate as immediate post-breakfast measurements may not provide accurate results.

A. A piston syringe. B. Barrier ointment. C. Chilled irrigation solution. D. Sterile cotton balls.

Correct Answer is A

Explanation

Choice A rationale:

The correct answer. A piston syringe is used for wound irrigation to deliver a controlled and directed flow of fluid to clean the wound. It helps remove debris and promote healing. This choice aligns with wound irrigation best practices.

Choice B rationale:

Barrier ointment is not typically used for wound irrigation. Its purpose is to protect intact skin from moisture, friction, and other irritants, rather than to clean wounds.

Choice C rationale:

Chilled irrigation solution is not commonly used for wound irrigation. Room temperature or warm sterile saline is usually recommended for wound cleansing as cold solutions can cause discomfort and vasoconstriction.

Choice D rationale:

Sterile cotton balls are not used for wound irrigation. They may leave fibers in the wound, potentially leading to infection. Wound irrigation is usually performed using sterile syringes, solutions, and appropriate irrigation devices.

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A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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