A pediatrician has evaluated the child and has written new prescriptions.
The nurse is preparing to assist with a lumbar puncture. Which of the following actions should the nurse take? Select all that apply.
Apply pressure to the puncture site following the procedure.
Limit the child's fluid intake following the procedure.
Position the child in a prone position during the procedure.
Ensure the guardian has signed the consent form prior to the procedure.
Ensure the child voids prior to the procedure.
Insert an indwelling urinary catheter during the procedure.
Monitor for paresthesia and tingling in extremities following the procedure.
Correct Answer : A,D,E,G
A. Apply pressure to the puncture site following the procedure. Applying pressure helps prevent cerebrospinal fluid (CSF) leakage and reduces the risk of complications.
B. Limit the child's fluid intake following the procedure. Fluids should be encouraged to help replenish lost CSF and reduce the risk of post-lumbar puncture headache.
C. Position the child in a prone position during the procedure. The correct positioning for a lumbar puncture is the side-lying fetal position or sitting with the back curved forward to widen the space between the vertebrae.
D. Ensure the guardian has signed the consent form prior to the procedure. A lumbar puncture is an invasive procedure, so informed consent is required before proceeding.
E. Ensure the child voids prior to the procedure. Having the child empty their bladder before the procedure helps prevent discomfort and reduces the risk of bladder distention during positioning.
F. Insert an indwelling urinary catheter during the procedure. A urinary catheter is not necessary for a lumbar puncture unless there is another medical indication.
G. Monitor for paresthesia and tingling in extremities following the procedure. Paresthesia or tingling could indicate nerve irritation or injury, which requires prompt assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Lymphadenopathy. While some viral infections cause lymph node swelling, lymphadenopathy is not a hallmark sign of rubeola (measles).
B. Steatorrhea. Steatorrhea (fatty stools) is associated with conditions like cystic fibrosis and celiac disease, not rubeola.
C. Koplik spots. Koplik spots are small, white lesions with a red base found on the buccal mucosa, and they are a classic early sign of measles (rubeola).
D. Paroxysmal coughing. Paroxysmal coughing is characteristic of pertussis (whooping cough), not rubeola.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
Temperature: The temperature decreased from 38.8° C (101.8° F) to 37.6° C (99.7° F), which indicates a potential improvement in the infection response as the body temperature is coming down.
WBC count: The WBC count increased slightly from 14,000/mm³ to 15,000/mm³, which is still elevated compared to the normal range (5,000 to 10,000/mm³). This suggests that the body is still responding to infection and could indicate a worsening condition if the trend continues or remains elevated.
Weight-bearing ability on the affected leg: The improvement in weight-bearing ability suggests that the condition of the leg is improving. This indicates that the condition is improving as the pain or swelling may have decreased.
Wound assessment: The wound culture is still pending, and although there is no specific description provided, a pending culture and the general condition of the wound (which can be assessed for redness, warmth, or exudate) might still indicate a worsening condition if there is continued inflammation or signs of spreading cellulitis.
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