The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern?
Client states a piercing feeling.
Physician maintains aseptic procedure.
Client states pressure relief in the head.
Cerebrospinal fluid is cloudy in nature.
The Correct Answer is D
Cerebrospinal fluid is cloudy in nature. Cloudy cerebrospinal fluid is a sign of infection or inflammation in the central nervous system, and lumbar puncture can be used to obtain cerebrospinal fluid for diagnostic purposes. The nurse should report this finding immediately to the physician for further evaluation and management.
Choice A, client states a piercing feeling, is incorrect because a piercing feeling is common during the procedure due to the insertion of the needle into the subarachnoid space.
Choice B, physician maintains aseptic procedure, is incorrect because maintaining aseptic technique during the procedure is standard protocol to prevent infection.
Choice C, client states a pressure relief in the head, is incorrect because this is not a concerning finding during the procedure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
sigmoid. A double-barrel colostomy involves surgically creating two separate stomas from the colon, with the proximal stoma discharging stool and the distal stoma discharging mucus. This type of colostomy is typically performed in the sigmoid colon, which is the S-shaped segment of the large intestine located just before the rectum.
Choice A, ascending, is not the correct answer because an ascending colostomy is created in the ascending colon, which is located on the right side of the abdomen.
Choice B, descending, is not the correct answer because a descending colostomy is created in the descending colon, which is located on the left side of the abdomen.
Choice C, transverse, is not the correct answer because a transverse colostomy is created in the transverse colon, which is located across the upper abdomen.
Correct Answer is A
Explanation
Increased pulse rate, adventitious breath sounds. Guillain-Barré syndrome (GBS) is a rare autoimmune disorder that affects the peripheral nervous system. It can cause weakness, paralysis, and difficulty breathing. Increased pulse rate and adventitious breath sounds, such as crackles or wheezes, may indicate that the client is experiencing respiratory distress and needs oral suctioning. Increased pulse rate and respirations of 16 breaths/minute, choice B, may indicate anxiety or pain but are not necessarily indicative of the need for oral suctioning.
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