A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)

Monitor the puncture site for hematoma.

Elevate the client’s head of bed.

Insert a urinary catheter.

Encourage fluid intake.

Apply a cervical collar to the client.

Answer and Explanation

Correct Answer : A,D

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.

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Correct Answer is C

Explanation

Choice A rationale
Cabbage is not a significant source of potassium. While it is a healthy vegetable, it does not provide the necessary potassium to help raise serum potassium levels.
Choice B rationale
Cheddar cheese is also not a high-potassium food. It is rich in calcium and protein but does not significantly contribute to potassium intake.
Choice C rationale
Bananas are well-known for their high potassium content. Including bananas in the diet can help increase serum potassium levels, which is beneficial for a client taking furosemide, a diuretic that can cause potassium loss.

Choice D rationale
Potatoes are another excellent source of potassium. However, the question specifies choosing one food, and bananas are a more commonly recommended option for increasing potassium intake.

A. Apply an ice pack to painful joints for 20 minutes, 3 times a day. B. Take a dose of aspirin on days when you have more pain. C. Increase your water intake to 2 liters per day. D. Participate in high impact aerobics to increase joint mobility.

Correct Answer is C

Explanation

Choice A rationale
Applying an ice pack to painful joints can help reduce inflammation and numb the area, providing temporary pain relief. However, it is not a recommended long-term strategy for managing osteoarthritis pain. Heat therapy is often more effective for chronic pain associated with osteoarthritis.
Choice B rationale
Taking aspirin on days with more pain is not recommended for osteoarthritis management. Aspirin is an NSAID and can cause gastrointestinal side effects with long-term use.
Acetaminophen is preferred for managing osteoarthritis pain due to its lower risk of side effects.
Choice C rationale
Increasing water intake to 2 liters per day is beneficial for overall health and can help maintain joint lubrication. Proper hydration is important for joint health and can help reduce the risk of further joint damage.
Choice D rationale
High-impact aerobics are not recommended for individuals with osteoarthritis as they can exacerbate joint pain and damage. Low-impact exercises such as swimming, cycling, and walking are better options for maintaining joint mobility and reducing pain.

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A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

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