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
Abduction is the correct position for the client’s right leg following a right total hip arthroplasty. This position helps prevent dislocation of the hip joint by keeping the leg away from the midline.
Choice B rationale
Internal rotation should be avoided as it can increase the risk of hip dislocation. This position places stress on the new hip joint.
Choice C rationale
External rotation is also not recommended as it can lead to dislocation of the hip joint. Proper alignment is crucial for healing.
Choice D rationale
Adduction, or moving the leg towards the midline, should be avoided as it significantly increases the risk of hip dislocation. Keeping the leg in abduction helps maintain joint stability.

Correct Answer is ["2"]

Explanation

Step 1: Calculate the number of tablets needed. 275 mcg ÷ 137 mcg/tablet = 2.007 tablets

Step 2: Round to the nearest whole number. 2.007 tablets ≈ 2 tablets The nurse should administer 2 tablets.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client’s right leg?

Correct Answer is A

Explanation

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?

Correct Answer is ["2"]

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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.)