A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?

Position the client flat as directed.

Leave the client to rest and do not perform any assessments.

Provide caffeine-rich drinks to the client.

Avoid administering analgesic agents to the client.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Positioning the client flat as directed is the priority intervention after a lumbar puncture to prevent cerebrospinal fluid (CSF) leakage, which can lead to a post-lumbar puncture headache. This position helps maintain normal CSF pressure and promotes sealing of the puncture site.

Choice B rationale

Leaving the client to rest without performing any assessments is not appropriate, as continuous monitoring is necessary to detect any complications such as bleeding or changes in neurological status. Regular assessments help ensure timely intervention if issues arise.

Choice C rationale

Providing caffeine-rich drinks is sometimes recommended to alleviate headaches caused by CSF leakage post-lumbar puncture. However, it is not the priority intervention immediately after the procedure, which focuses on positioning and monitoring.

Choice D rationale

Avoiding analgesic agents is incorrect. Pain management is an important aspect of care post-lumbar puncture, and appropriate analgesics should be administered as needed. The focus should be on positioning and monitoring, not withholding pain relief.

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

Explanation

Choice A rationale

Palpating the client's skin for moisture, temperature, and texture is essential in wound management. This allows the nurse to assess for signs of infection or inflammation, which can affect the wound healing process. Moisture can indicate excessive drainage or sweating that might macerate the skin, while changes in temperature and texture can signify infection or poor blood flow.

Choice B rationale

While asking the client whether the wound bed or surrounding skin itches may provide some information about the client's comfort, it is not a primary intervention for wound management. Itching can be a sign of healing or irritation, but it does not provide direct information on the wound's condition.

Choice C rationale

Measuring and assessing the wound bed, size, edges, and margins are critical steps in wound management. This helps to determine the progression of healing, the presence of necrotic tissue, and any changes in the wound over time. Accurate measurement and documentation are essential for developing an appropriate care plan.

Choice D rationale

Evaluating the client's level of pain using a numeric value pain scale is important in wound management. Pain can indicate underlying issues such as infection, poor perfusion, or neuropathy. Assessing pain helps guide interventions to provide comfort and address any complications that may arise.

Choice E rationale

Reviewing the client's prothrombin time test and international normalized ratio is not a standard intervention for wound management. These tests are more relevant to assessing the client's coagulation status, which may be important for surgical or anticoagulant therapy but not directly for wound care.

A. Ativan. B. Cerebyx. C. Phenobarbital. D. Valium.

Correct Answer is C

Explanation

Choice A rationale

Ativan (lorazepam) is used for immediate control of seizures but is not used for long-term maintenance.

Choice B rationale

Cerebyx (fosphenytoin) is used for seizure control but is generally not used for long-term maintenance.

Choice C rationale

Phenobarbital is a barbiturate that is commonly used for long-term maintenance to prevent seizures. It works by depressing the central nervous system and reducing the spread of seizure activity.

Choice D rationale

Valium (diazepam) is used for acute seizure control but not for long-term seizure prevention.

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A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses two new wounds located on a client's right and left buttocks. Which intervention for wound management would the nurse employ? Select all that apply.

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

Explanation

Which of the following drugs may be used after a seizure to maintain a seizure-free state?

Correct Answer is C

Explanation

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