Exhibits

The nurse should plan to first administer 

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B. After a lumbar puncture, instructing the client to lie flat on their back for a period of time (often 1-2 hours) helps prevent complications such as headaches due to CSF leakage and promotes proper sealing of the puncture site.

A Monitoring blood glucose every 2 hours is not typically necessary immediately following a lumbar puncture unless the client has pre-existing diabetes or there are specific indications to monitor glucose levels

C Tingling in the extremities is not an expected or normal occurrence following a lumbar puncture. It could indicate neurological complications such as nerve irritation or damage, which would require prompt assessment and intervention.

D. The nurse should encourage adequate hydration unless contraindicated by the client's medical condition or specific post-procedure instructions.

B. This is often the nurse's top priority in the PACU. Anesthesia can depress respiratory function, leading to hypoventilation or airway obstruction. The nurse assesses respiratory rate, effort, oxygen saturation, and auscultates breath sounds to ensure adequate ventilation. Addressing any respiratory compromise promptly is crucial to prevent hypoxia or respiratory arrest.

A Assessing the surgical site is important to monitor for bleeding, infection, or any other complications related to the procedure. However, immediately after surgery, other assessments take precedence over this unless there is a specific concern like excessive bleeding or signs of infection.

C. Monitoring the client's level of consciousness is vital to detect any signs of neurological complications or delayed emergence from anesthesia. The nurse assesses orientation, responsiveness, and neurological signs to ensure the client is awakening appropriately from anesthesia.

D. Assessing pain is important as clients may experience discomfort after surgery. Pain can also affect respiratory function and overall recovery. However, it is typically assessed after ensuring respiratory status and consciousness are stable, as uncontrolled pain can be managed once immediate physiological concerns are addressed.