Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that the client is experiencing a complication of the procedure?

"I have a headache that gets worse when I sit up."

"I am having pain in my lower back when I move my legs."

"I feel sick to my stomach and am going to throw up."

"My throat hurts badly when I swallow and when I talk."

Answer and Explanation

The Correct Answer is A

A. A headache that worsens upon sitting up is characteristic of a post-lumbar puncture headache, indicating a potential complication related to cerebrospinal fluid leakage.

B. Pain in the lower back after the procedure can be normal and does not necessarily indicate a complication.

C. Nausea and vomiting can occur but are not specific indicators of a complication following a lumbar puncture.

D. Sore throat when swallowing and talking is not typically associated with lumbar puncture complications and may relate to other causes such as anxiety or dehydration.

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Correct Answer is A

Explanation

A. Selecting another finger is the best action to prevent discomfort and ensure an accurate blood sample. The reddened and engorged tip may indicate that milking the finger caused bruising or altered blood flow, which can affect the glucose reading.

B. Applying pressure to the site may be appropriate after collecting a sample, but it does not address the issue of obtaining an accurate sample from an engorged finger.

C. Assessing radial pulse volume is not relevant in this situation and does not address the problem at hand.

D. Collecting the blood sample from a reddened and engorged finger could yield an inaccurate result, so it is better to select a different finger.

Correct Answer is ["100"]

Explanation

Infusion rate (mL/hr) = Volume to be infused (mL) / Time (hr)

In this case:

Volume to be infused = 2 liters = 2000 mL
Time = 20 hours

Plugging the values into the formula:

Infusion rate = 2000 mL / 20 hours = 100 mL/hr

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Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that the client is experiencing a complication of the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

Correct Answer is A

Explanation

A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 20 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Correct Answer is ["100"]

Explanation

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A client receives a prescription for 1 L of lactated Ringers to be infused IV over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

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