A nurse is preparing to administer ondansetron 4 mg IM stat.

The amount available is ondansetron for injection 2 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number.

(Use a leading zero if it applies. Do not use a trailing zero)

Choice A rationale
Monitoring the puncture site for hematoma is crucial because a hematoma can indicate bleeding at the puncture site, which can lead to complications such as infection or nerve damage. Hematomas can also cause increased intracranial pressure, which can be dangerous for the patient. Therefore, it is essential to monitor the site closely to ensure that any signs of bleeding are detected early and managed appropriately.
Choice B rationale
Elevating the client’s head of bed is incorrect because it can increase the risk of cerebrospinal fluid (CSF) leakage from the puncture site. After a lumbar puncture, it is recommended to keep the patient in a flat position for several hours to reduce the risk of post-lumbar puncture headache and to allow the puncture site to heal properly. Elevating the head of the bed too soon can disrupt this process and lead to complications.
Choice C rationale

Inserting a urinary catheter is incorrect because it is not a standard procedure following a lumbar puncture. The primary focus after a lumbar puncture is to monitor for complications related to the procedure itself, such as bleeding, infection, or CSF leakage. Inserting a urinary catheter is not necessary unless there is a specific indication for it, such as urinary retention or other urological issues.
Choice D rationale
Encouraging fluid intake is correct because it helps to replenish the CSF that was removed during the lumbar puncture. Increased fluid intake can also help to reduce the risk of post- lumbar puncture headache, which is a common complication. Hydration is important for overall recovery and helps to maintain normal bodily functions.
Choice E rationale
Applying a cervical collar to the client is incorrect because it is not related to the care of a lumbar puncture site. A cervical collar is typically used for patients with neck injuries or conditions affecting the cervical spine. It has no role in the management of a lumbar puncture site and would not provide any benefit in this context.

Choice A rationale
Osteoarthritis is caused by inflammation that affects both joints and other body tissues is incorrect. This description is more characteristic of rheumatoid arthritis, which is an autoimmune disease that causes systemic inflammation.
Choice B rationale
Osteoarthritis occurs due to the aging process and results in disintegration of cartilage in a joint is correct. Osteoarthritis is a degenerative joint disease that primarily affects the cartilage, leading to its breakdown over time.
Choice C rationale
Osteoarthritis is due to loss of calcium in the bones, which can lead to increased risk for bone fractures is incorrect. This description is more characteristic of osteoporosis, a condition that weakens bones and makes them more prone to fractures.
Choice D rationale
Osteoarthritis happens in several phases when deposits of crystals develop in joints and soft tissues is incorrect. This description is more characteristic of gout, a type of arthritis caused by the deposition of urate crystals in the joints.