A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take?

Instruct the client to expect tingling in their extremities.

Measure blood glucose every 2 hours.

Limit the client's fluid intake.

Instruct the client to lie flat.

Answer and Explanation

The Correct Answer is D

Choice A reason: Instructing the client to expect tingling in their extremities is not a standard post-lumbar puncture care instruction. Tingling may be a sign of nerve irritation or damage, which is not an expected outcome and should be reported if it occurs.

Choice B reason: Measuring blood glucose every 2 hours is not related to post-lumbar puncture care unless the client has a specific condition that requires such monitoring. Post-lumbar puncture care focuses on preventing complications such as headaches and monitoring for signs of infection or bleeding.

Choice C reason: Limiting the client's fluid intake is not advised following a lumbar puncture. In fact, increasing fluid intake can help prevent the occurrence of post-lumbar puncture headaches, which are a common complication. Adequate hydration helps replenish cerebrospinal fluid and reduce headache severity.

Choice D reason: Instructing the client to lie flat is the correct action. After a lumbar puncture, it is recommended that the client lies flat for several hours to prevent the leakage of cerebrospinal fluid from the puncture site, which can lead to a spinal headache. Lying flat helps maintain normal cerebrospinal fluid pressure and reduces the risk of headache.

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Correct Answer is B

Explanation

Choice A reason: Pressing down on the orbital area of the eye is not a recommended method for eliciting a pain response due to the risk of causing injury to the eye.

Choice B reason: Pinching the trapezius muscle is a common and safe method to elicit a pain response in an unresponsive patient. It is less invasive and carries a lower risk of injury compared to other methods.

Choice C reason: Using a 25-gauge needle is not a standard practice for eliciting a pain response due to the risk of puncture and infection.

Choice D reason: Eliciting a reflex with a reflex hammer is used to assess neurological function, not to elicit a pain response in an unresponsive patient.

A. Perform a Mantoux skin test on the client. B. Assign the client to a negative-pressure airflow room. C. Wear a surgical mask when providing care to the client. D. Recommend that the client's family members receive antiviral therapy.

Correct Answer is C

Explanation

The correct answer is: c. Wear a surgical mask when providing care to the client.

Choice A: Perform a Mantoux skin test on the client

The Mantoux skin test is used to screen for tuberculosis, not pertussis. Pertussis, also known as whooping cough, is a bacterial infection caused by Bordetella pertussis. The Mantoux test would not be relevant or helpful in diagnosing or managing pertussis.

Choice B: Assign the client to a negative-pressure airflow room

Negative-pressure airflow rooms are typically used for airborne infections such as tuberculosis, measles, or varicella. Pertussis is primarily spread through respiratory droplets, not airborne transmission, so a negative-pressure room is not necessary.

Choice C: Wear a surgical mask when providing care to the client

Wearing a surgical mask is appropriate when caring for a client with pertussis. Pertussis is spread through respiratory droplets, and wearing a mask helps prevent the transmission of the bacteria to healthcare workers and other patients.

Choice D: Recommend that the client’s family members receive antiviral therapy

Antiviral therapy is not effective against pertussis, which is a bacterial infection. Instead, antibiotics such as azithromycin or erythromycin are used to treat pertussis and prevent its spread. Therefore, recommending antiviral therapy would not be appropriate.

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A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is exhibiting an altered level of consciousness and is unresponsive to verbal stimuli. To elicit a response from a painful stimulus, the nurse would:

Correct Answer is B

Explanation

A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

Choice A: Perform a Mantoux skin test on the client

Choice B: Assign the client to a negative-pressure airflow room

Choice C: Wear a surgical mask when providing care to the client

Choice D: Recommend that the client’s family members receive antiviral therapy

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