A nurse is performing a lumbar puncture on a child who has suspected meningitis. What statement by the nurse would indicate that the procedure is done correctly and safely?

"I will insert the needle between the third and fourth lumbar vertebrae and collect the cerebrospinal fluid."

"I will position you on your side with your knees drawn up to your chest and your chin tucked to your chest."

"I will apply a sterile dressing to the puncture site and monitor you for any signs of infection or bleeding."

"I will give you some pain medication before the procedure and ask you to report any pain or discomfort during the procedure."

Answer and Explanation

The Correct Answer is B

Choice A reason: This statement by the nurse would not indicate that the procedure is done correctly and safely, as it does not describe the correct anatomical landmark for a lumbar puncture. The needle should be inserted between the fourth and fifth lumbar vertebrae, not the third and fourth, to avoid damaging the spinal cord.

Choice B reason: This statement by the nurse would indicate that the procedure is done correctly and safely, as it describes the correct position for a lumbar puncture. The lateral recumbent position with flexion of the spine helps expose the intervertebral spaces and facilitate the insertion of the needle.

Choice C reason: This statement by the nurse would not indicate that the procedure is done correctly and safely, as it describes the post-procedure care, not the procedure itself. Applying a sterile dressing and monitoring for signs of infection or bleeding are important steps to prevent complications after a lumbar puncture, but they do not ensure that the procedure is done correctly and safely.

Choice D reason: This statement by the nurse would not indicate that the procedure is done correctly and safely, as it describes the pre-procedure and intra-procedure care, not the procedure itself. Giving pain medication and asking for pain or discomfort are important steps to reduce anxiety and discomfort during a lumbar puncture, but they do not ensure that the procedure is done correctly and safely.

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Correct Answer is C

Explanation

Choice A reason: This is not the correct answer, as pain is not the most common type of procedure-related injury for a child who has a burn injury. Pain is an expected outcome of a burn injury and its treatment, but it can be managed with appropriate analgesics and non-pharmacological interventions.

Choice B reason: This is not the correct answer, as bleeding is not the most common type of procedure-related injury for a child who has a burn injury. Bleeding may occur during debridement or grafting of the wound, but it can be controlled with pressure dressing and hemostatic agents.

Choice C reason: This is the correct answer, as infection is the most common type of procedure-related injury for a child who has a burn injury. Infection may occur due to loss of skin barrier, exposure to microorganisms, or impaired immune response. The nurse should clean and dress the wound with sterile technique and monitor the child's temperature and white blood cell count to prevent or detect infection.

Choice D reason: This is not the correct answer, as allergic reaction is not the most common type of procedure-related injury for a child who has a burn injury. Allergic reaction may occur due to hypersensitivity to medications, dressings, or grafts, but it can be prevented or treated with antihistamines or corticosteroids.

A. Check the medication label against the medication administration record (MAR) three times before giving the medication. B. Use an oral syringe or dropper to measure and administer liquid medication. C. Ask another nurse to verify the medication dosage and calculation. D. Compare the infant's identification band with the MAR and ask the parent to confirm the infant's name. E. Crush or dissolve any tablets or capsules and mix them with formula or juice.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason: This action should be taken by the nurse to prevent medication errors, as it helps ensure that the medication is correct in terms of name, dose, route, time, and patient.

Choice B reason: This action should be taken by the nurse to prevent medication errors, as it helps ensure that the medication is measured and administered accurately and safely. Oral syringes or droppers are more precise and easier to use than cups or spoons for liquid medication.

Choice C reason: This action should be taken by the nurse to prevent medication errors, as it helps ensure that the medication dosage and calculation are correct and appropriate for the patient's weight and age. Another nurse can act as a double-check and catch any potential errors or discrepancies.

Choice D reason: This action should be taken by the nurse to prevent medication errors, as it helps ensure that the medication is given to the right patient. Comparing the infant's identification band with the MAR and asking the parent to confirm the infant's name are two ways of verifying the patient's identity.

Choice E reason: This action should not be taken by the nurse to prevent medication errors, as it may alter the effectiveness, absorption, or taste of the medication. Crushing or dissolving tablets or capsules and mixing them with formula or juice may also cause choking or aspiration in infants. The nurse should only administer medications that are in liquid form or prescribed to be crushed or dissolved.

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A nurse is performing a lumbar puncture on a child who has suspected meningitis. What statement by the nurse would indicate that the procedure is done correctly and safely?

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A nurse is performing a lumbar puncture on a child who has suspected meningitis. What statement by the nurse would indicate that the procedure is done correctly and safely?