The nurse is caring for a patient undergoing a lumbar puncture by the provider. Select the priority nursing intervention the nurse would complete after the procedure.

Maintain pressure to the puncture site and observe for drainage.

Complete a pain assessment and administer an ordered analgesic, as needed.

Inform the patient they may feel pressure and sharp pain in their lower back for several hours.

Assess pulses distal to the lumbar puncture site every two hours.

Answer and Explanation

The Correct Answer is A

Choice A reason: Maintaining pressure to the puncture site and observing for drainage is the priority nursing intervention for a patient who had a lumbar puncture. It helps to prevent bleeding, hematoma, and cerebrospinal fluid leakage, which can cause complications such as infection, headache, or nerve damage.

Choice B reason: Completing a pain assessment and administering an ordered analgesic, as needed, is an important nursing intervention for a patient who had a lumbar puncture, but it is not the priority. Lumbar puncture can cause mild to moderate pain and discomfort at the puncture site, which can be relieved by analgesics, ice packs, or massage.

Choice C reason: Informing the patient they may feel pressure and sharp pain in their lower back for several hours is an important nursing intervention for a patient who had a lumbar puncture, but it is not the priority. Lumbar puncture can cause transient sensations of pressure and pain in the lower back, which can be reduced by lying flat, avoiding sudden movements, and drinking fluids.

Choice D reason: Assessing pulses distal to the lumbar puncture site every two hours is not an appropriate nursing intervention for a patient who had a lumbar puncture. Lumbar puncture does not affect the blood circulation to the lower extremities, unless there is a complication such as hematoma or nerve compression. Therefore, the nurse should monitor the neurological status, vital signs, and signs of infection or bleeding.

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Correct Answer is A

Explanation

Choice A reason: The hypoglossal nerve is responsible for the movement of the tongue. It innervates the muscles of the tongue and allows for speech, swallowing, and chewing.

Choice B reason: The trigeminal nerve is responsible for the sensation and motor function of the face. It innervates the muscles of mastication, the skin of the face, and the mucous membranes of the mouth and nose.

Choice C reason: The facial nerve is responsible for the expression and taste of the face. It innervates the muscles of facial expression, the lacrimal and salivary glands, and the anterior two-thirds of the tongue.

Choice D reason: The vestibulocochlear nerve is responsible for the hearing and balance of the ear. It innervates the cochlea and the vestibular apparatus of the inner ear.

A. macrocytic, normochromic B. microcytic, hypochromic C. normocytic, normochromic D. microcytic, normochromic

Correct Answer is A

Explanation

Choice A reason: This is correct. Folic acid deficiency causes macrocytic, normochromic anemia, which means that the red blood cells are larger than normal, but have normal color and hemoglobin content. Folic acid is a vitamin that is needed for the synthesis of DNA and the maturation of red blood cells.

Choice B reason: This is incorrect. Microcytic, hypochromic anemia means that the red blood cells are smaller than normal and have less color and hemoglobin content. This type of anemia is caused by iron deficiency, not folic acid deficiency.

Choice C reason: This is incorrect. Normocytic, normochromic anemia means that the red blood cells are normal in size, color, and hemoglobin content, but there are fewer of them. This type of anemia is caused by blood loss, hemolysis, or bone marrow failure, not folic acid deficiency.

Choice D reason: This is incorrect. Microcytic, normochromic anemia means that the red blood cells are smaller than normal, but have normal color and hemoglobin content. This type of anemia is rare and is caused by disorders of red blood cell production, such as thalassemia or sideroblastic anemia, not folic acid deficiency.

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The nurse is caring for a patient undergoing a lumbar puncture by the provider. Select the priority nursing intervention the nurse would complete after the procedure.

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