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
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Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A. Ventilator-associated pneumonia (VAP) is a common HAI that occurs in patients who have been mechanically ventilated for an extended period. The presence of a ventilator increases the risk of introducing pathogens into the lower respiratory tract, leading to pneumonia.
B. Catheter-associated urinary tract infection (CAUTI) is an HAI that occurs due to the use of urinary catheters. Indwelling urinary catheters can introduce bacteria into the urinary tract, increasing the risk of infection.
C. Surgical site infections (SSIs) are infections that occur after surgery in the part of the body where the surgery took place. They are a significant cause of morbidity and mortality and are considered HAIs when they occur in healthcare settings.
D. Influenza acquired from a coworker is not typically considered a healthcare-associated infection. It is usually acquired in community settings rather than healthcare facilities.
E. Central line-associated bloodstream infections (CLABSIs) occur when bacteria or other pathogens enter the bloodstream through a central venous catheter. These infections are considered HAIs because they are associated with the presence of a central venous catheter used for medical treatment.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}
Explanation
The client reports symptoms of vomiting and diarrhea for the past 12 hours. These symptoms are classic indicators of fluid loss from the gastrointestinal tract. Vomiting and diarrhea lead to significant fluid depletion, resulting in a fluid volume deficit. This deficit can lead to dehydration, electrolyte imbalances, and potentially hypotension (low blood pressure), which are consistent with the client's clinical presentation of tachycardia (increased heart rate) and hypotension (blood pressure 102/58 mmHg). The plan for IV fluid replacement upon admission reflects the need to address and correct this fluid deficit.
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