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 A

Explanation

Choice A rationale

Difficulty starting the flow of urine is a common symptom of benign prostatic hyperplasia (BPH). This condition involves the enlargement of the prostate gland, which can obstruct the urethra and make it difficult to initiate urination.
Choice B rationale
Painful urination is not typically associated with BPH. It is more commonly linked to urinary tract infections or other conditions such as prostatitis.
Choice C rationale
Urge incontinence is not a primary symptom of BPH. While BPH can cause urinary frequency and urgency, urge incontinence is more often related to overactive bladder syndrome.
Choice D rationale
Critically elevated prostate-specific antigen (PSA) levels are not a direct symptom of BPH. Elevated PSA levels can be indicative of prostate cancer or other prostate conditions, but not specifically BPH12.

A. Respiratory alkalosis. B. Respiratory acidosis. C. Metabolic acidosis. D. Metabolic alkalosis.

Correct Answer is B

Explanation

Choice A rationale
Respiratory alkalosis is incorrect. Respiratory alkalosis is characterized by a high pH and low PaCO₂, which is not consistent with the given ABG values. The client’s pH is low (7.22), indicating acidosis, and the PaCO₂ is high (68 mm Hg), indicating a respiratory cause.
Choice B rationale
Respiratory acidosis is correct. Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO₂) in the blood, leading to a decrease in pH. The given ABG values show a low pH (7.22) and a high PaCO₂ (68 mm Hg), which are indicative of respiratory acidosis. The elevated bicarbonate (28 mEq/L) suggests partial compensation by the kidneys.
Choice C rationale
Metabolic acidosis is incorrect. Metabolic acidosis is characterized by a low pH and low bicarbonate (HCO₃⁻) levels. In this case, the bicarbonate level is elevated (28 mEq/L), which is not consistent with metabolic acidosis. The primary issue is respiratory, as indicated by the high PaCO₂.
Choice D rationale
Metabolic alkalosis is incorrect. Metabolic alkalosis is characterized by a high pH and high bicarbonate levels. The given ABG values show a low pH (7.22), which indicates acidosis, not alkalosis. Additionally, the primary issue is respiratory, as indicated by the high PaCO₂.

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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.)

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