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 is: 275 mcg ÷ 137 mcg/tablet = 2.007 tablets The final calculated answer is 2 tablets.

A. Review stress factors that can cause disease exacerbation. B. Evaluate fluid and electrolyte levels. C. Promote physical mobility. D. Provide emotional support.

Correct Answer is B

Explanation

Choice A rationale
While reviewing stress factors is important, it is not the priority action during an acute exacerbation of ulcerative colitis. The immediate concern is to address the physical symptoms and stabilize the patient.
Choice B rationale
Evaluating fluid and electrolyte levels is the priority action because acute exacerbations of ulcerative colitis can lead to significant fluid loss and electrolyte imbalances. Prompt assessment and correction of these imbalances are crucial for patient stability.
Choice C rationale

Promoting physical mobility is important for overall health but is not the priority during an acute exacerbation. The focus should be on managing the acute symptoms and stabilizing the patient.
Choice D rationale
Providing emotional support is important but is not the priority action during an acute exacerbation. The immediate concern is to address the physical symptoms and stabilize the patient.

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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 275 mcg PO to a client. The amount available is levothyroxine 137 mcg/tablet. How many tablets should the nurse administer? (Round to the nearest whole number. Use a leading zero if it applies. (Do not use a trailing zero)

Correct Answer is ["2"]

Explanation

A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority?

Correct Answer is B

Explanation

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