A nurse is providing teaching to a client who is scheduled for a bone marrow biopsy taken from the iliac crest. Which of the following information should the nurse include?
“Avoid strenuous activities for 1 week following the procedure.”
“You will lie on your back during the procedure.”
“You will receive general anesthesia for the procedure.”
“Take acetaminophen as prescribed for pain relief after the procedure.”
The Correct Answer is D
Choice A Reason
“Avoid strenuous activities for 1 week following the procedure.” This statement is partially correct. While it is advisable to avoid strenuous activities, the exact duration can vary. Typically, patients are advised to avoid heavy lifting and vigorous activities for a few days to a week, depending on their recovery.
Choice B Reason
“You will lie on your back during the procedure.” This statement is incorrect. For a bone marrow biopsy from the iliac crest, the patient usually lies on their side or stomach to allow access to the hip bone. Lying on the back would not provide the necessary access for the procedure.
Choice C Reason
“You will receive general anesthesia for the procedure.” This statement is incorrect. Bone marrow biopsies are usually performed under local anesthesia to numb the area. General anesthesia is not typically required. The patient may also receive a mild sedative to help them relax.
Choice D Reason
“Take acetaminophen as prescribed for pain relief after the procedure.” This is the correct statement. Acetaminophen is commonly recommended for pain relief after a bone marrow biopsy because it is effective and has fewer side effects compared to other pain medications like NSAIDs, which can increase the risk of bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
A distended, board-like abdomen is a critical finding that can indicate peritonitis, a severe complication of appendicitis. Peritonitis occurs when the appendix ruptures, leading to infection spreading throughout the abdominal cavity. This condition requires immediate medical intervention to prevent further complications and potential sepsis.
Choice B Reason:
A WBC count of 15,000/mm³ is elevated and suggests an infection, which is common in appendicitis. However, it is not as immediately critical as signs of peritonitis. Elevated WBC counts are expected in cases of appendicitis but do not necessarily indicate a life-threatening emergency.
Choice C Reason:
Rebound tenderness over McBurney’s point is a classic sign of appendicitis and indicates localized inflammation. While it is an important diagnostic sign, it does not require immediate reporting compared to signs of peritonitis.
Choice D Reason:
A temperature of 37.3°C (99.1°F) is only slightly elevated and does not indicate a severe infection or complication. Fever is a common symptom of appendicitis but is not as critical as a distended, board-like abdomen.
Correct Answer is ["A","B","C"]
Explanation
Choice A Reason:
Infection is a significant complication of a ventriculostomy drain. The presence of a foreign object in the brain increases the risk of infections such as meningitis or ventriculitis. Signs of infection can include fever, redness, swelling at the insertion site, and changes in mental status.
Choice B Reason:
Vomiting can be a sign of increased intracranial pressure (ICP), which is a serious complication in clients with a traumatic brain injury and a ventriculostomy drain. Increased ICP can lead to further brain injury and requires immediate medical attention.
Choice C Reason:
Widening pulse pressure (the difference between systolic and diastolic blood pressure) can indicate increased intracranial pressure. This is a critical finding that should be reported immediately as it can signify worsening brain injury or other complications.
Choice D Reason:
Equal and reactive pupils are generally a normal finding and do not indicate a complication. This suggests that the brainstem is functioning properly and there is no significant increase in intracranial pressure affecting the cranial nerves.
Choice E Reason:
An intracranial pressure reading of 10 mm Hg is within the normal range (typically 7-15 mm Hg for adults). Therefore, this finding does not indicate a complication and does not require immediate reporting.
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