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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Necrosis. Necrosis is the death of cells or tissue due to disease, injury, or lack of blood supply. In the process of tissue injury, necrosis occurs in the deepest and most severe area of injury.
Choice A, Hyperemia is an increase in blood flow to an area, causing redness and warmth.
Choice B, Coagulation is the process of blood clotting.
Choice C, Stasis is a reduction in blood flow to an area, causing blood to pool and resulting in tissue hypoxia.
Correct Answer is D
Explanation
Diarrhea. A client who is recovering from bariatric surgery and is eating from a portable commode is at risk for diarrhea. Diarrhea can cause fluid and electrolyte imbalances, leading to dehydration, which can be life-threatening, especially in the immediate postoperative period.
Option A, impaired mobility, would not be a priority concern in the immediate postoperative period for this client.
Option B, impaired gas exchange, is not related to the situation.
Option C, self-care deficit, maybe a concern but is not as significant as diarrhea in the immediate postoperative period.
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