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 ["2"]

Explanation

Step 1: Determine the total dosage required. 100 mcg Step 2: Determine the dosage per tablet. 50 mcg per tablet Step 3: Calculate the number of tablets needed. 100 mcg ÷ 50 mcg/tablet = 2 tablets The nurse should administer 2 tablets.

A. Cabbage. B. Cheddar cheese. C. Bananas. D. Potatoes.

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.

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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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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer levothyroxine 100 mcg PO to a client who has hypothyroidism. Available is levothyroxine 50 mcg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies.(Do not use a trailing zero.=)

Correct Answer is ["2"]

Explanation

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Correct Answer is C

Explanation

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