A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure?
Transfer the patient to radiology.
Enforce NPO status for 4 hours.
Help the patient to a lateral position.
Administer a sedative medication.
The Correct Answer is C
A. Transfer the patient to radiology: Lumbar punctures are typically performed at the bedside in the patient's room or in a procedure room, not in radiology.
B. Enforce NPO status for 4 hours: NPO (nothing by mouth) status is not typically required before a lumbar puncture unless specifically ordered by the healthcare provider for a particular reason.
C. Help the patient to a lateral position: Before a lumbar puncture, the patient should be placed in a lateral recumbent position (usually on their side with knees flexed towards the chest) to facilitate the procedure and minimize the risk of complications such as post-dural puncture headache.
D. Administer a sedative medication: Sedative medications are not routinely administered before a lumbar puncture, as they can alter the patient's level of consciousness and interfere with neurological assessment during and after the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assess for the presence of chest pain: While chest pain should always be assessed in a comprehensive health history and physical examination, it is not specifically related to multiple sclerosis unless there are concurrent cardiac issues.
B. Inquire about urinary tract problems: Urinary symptoms such as urinary urgency, frequency, hesitancy, or incontinence are common in multiple sclerosis due to neurogenic bladder dysfunction. Therefore, it is essential to inquire about these symptoms to assess the extent of neurological involvement and provide appropriate management.
C. Inspect the skin for rashes or discoloration: While skin manifestations can occur in multiple sclerosis, they are less common and not typically primary concerns during initial assessment. However, if the patient reports skin changes, they should be evaluated accordingly.
D. Ask the patient about any increase in libido: Changes in libido are not typically associated with multiple sclerosis unless they are related to psychological or emotional factors. While sexual dysfunction can occur in MS, it is not the primary focus during the initial assessment unless the patient presents with related concerns.
Correct Answer is B
Explanation
A. Intracranial pressure: Monitoring intracranial pressure is important in clients with a history of subdural hematoma, but immediate assessment of respiratory status takes precedence in the immediate postoperative period to ensure adequate oxygenation and ventilation.
B. Respiratory status: Following evacuation of a subdural hematoma, the client may be at risk for respiratory compromise due to factors such as altered consciousness, impaired airway reflexes, or postoperative complications. Assessing respiratory rate, depth, oxygen saturation, and presence of respiratory distress is essential for early detection and intervention.
C. Temperature: Monitoring temperature is important for detecting signs of infection or systemic complications, but it is not the priority assessment immediately following evacuation of a subdural hematoma.
D. Serum electrolytes: While monitoring serum electrolytes is important for overall assessment and management of the client's condition, it is not the priority assessment in the immediate postoperative period following evacuation of a subdural hematoma.
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