A nurse is caring for a 20-year-old client who has a fever and reports severe headache.
A nurse is preparing the client for a lumbar puncture. Which of the following actions should the nurse take? Select all that apply.
Provide education about the procedure.
Place the client in a lateral position with the knees drawn to the abdomen.
Ensure informed consent is obtained.
Place client NPO for 4 to 6 hr.
Obtain coagulation studies.
Assess for allergies to contrast dyes.
Administer a soapsuds enema.
Administer IV sedation as prescribed.
Correct Answer : A,B,C,D,E
A. Educating the client about the lumbar puncture procedure is crucial for informed consent and to alleviate anxiety. The nurse should explain the purpose of the procedure, what the client will experience during the procedure (such as positioning, sensation of pressure), potential risks (like headache post- procedure), and benefits (diagnostic information for the healthcare provider).
B. Positioning the client correctly is important for the success and safety of the lumbar puncture. The lateral recumbent (side lying) position with the knees drawn up towards the abdomen helps to flex the spine and widen the spaces between the vertebrae in the lumbar region. This positioning makes it easier for the healthcare provider to access the spinal canal and perform the procedure accurately.
C. Informed consent is a legal and ethical requirement before performing any invasive procedure, including a lumbar puncture. The nurse must ensure that the client (or their legally authorized representative) understands the purpose of the procedure, its risks and benefits, alternative options (if any), and gives voluntary consent without coercion.
D. NPO (nothing by mouth) status helps reduce the risk of aspiration during the procedure, especially if the client needs sedation or if complications arise requiring emergency intubation. It ensures that the client's stomach is empty, minimizing the risk of vomiting and aspiration during the procedure.
E. Coagulation studies (such as PT/INR and PTT) may be ordered to assess the client's bleeding risk before performing a lumbar puncture. This is particularly important if there are concerns about bleeding disorders or if the client is on anticoagulant medications. Normal coagulation parameters are reassuring before proceeding with an invasive procedure.
F. Contrast dye is not typically used in a routine lumbar puncture.
G. Administering a soapsuds enema is not typically necessary before a lumbar puncture unless specifically indicated by the healthcare provider. It may be used in certain cases to reduce the risk of fecal contamination during the procedure, particularly if the client is constipated.
H. IV sedation is not routinely administered during a lumbar puncture in adult clients
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Tachycardia, or increased heart rate, can occur during hypoglycemia as a result of the body's response to low blood sugar levels. The sympathetic nervous system is activated, leading to increased adrenaline (epinephrine) release, which can cause palpitations and tachycardia.
B. Polydipsia refers to excessive thirst. It is typically a symptom of hyperglycemia (high blood sugar levels) rather than hypoglycemia. During hypoglycemia, thirst is not a common symptom.
C. Polyuria refers to excessive urination. Similar to polydipsia, it is more commonly associated with hyperglycemia (high blood sugar levels) rather than hypoglycemia. Hypoglycemia typically does not cause polyuria.
D. Blurred vision can occur during hypoglycemia due to changes in the shape of the lens in the eye caused by altered fluid balance due to low blood sugar levels.
E. Moist, clammy skin is a common manifestation of hypoglycemia. When blood sugar levels drop, the body's autonomic nervous system responds by releasing adrenaline, which can cause sweating and clamminess.
Correct Answer is A
Explanation
A. Calling the healthcare provider is a reasonable action, especially when there is a significant change in the patient's condition, such as weight gain and generalized edema. The nurse may need further guidance on adjusting medications or additional interventions.
B. Diuretics are commonly prescribed for patients with heart failure to manage fluid overload. If the patient has not been compliant with taking their diuretic as prescribed, it could contribute to fluid retention and exacerbation of symptoms. Therefore, ensuring medication adherence is important. However, this alone may not address the acute issue of current weight gain and edema.
C. Daily weight monitoring is crucial for patients with heart failure as it can indicate fluid retention early on. Reinforcing the importance of daily weights helps in early detection of changes and facilitates timely intervention. However, in this scenario, the nurse has already noted a significant weight gain and edema since the last visit, so immediate action beyond education is needed.
D. Documenting the findings is essential for maintaining accurate patient records. However, in the context of a patient with heart failure who has shown signs of worsening (weight gain and edema), immediate action to address the worsening condition is necessary.
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