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 B

Explanation

Choice A reason: This is incorrect. Anticoagulant therapy may be necessary to prevent pulmonary thrombosis in patients with ischemic stroke, which is caused by a blood clot blocking a blood vessel in the brain. However, in patients with hemorrhagic stroke, which is caused by a ruptured blood vessel in the brain, anticoagulant therapy can worsen the bleeding and increase the risk of complications.

Choice B reason: This is correct. Anticoagulant therapy is contraindicated because it will cause additional bleeding in patients with hemorrhagic stroke. Anticoagulants are drugs that prevent blood from clotting or dissolve existing clots. They can increase the size of the hematoma and the pressure on the brain tissue, leading to more damage and disability.

Choice C reason: This is incorrect. Anticoagulant therapy is not inadvisable because it may mask signs and symptoms of neurologic changes in the brain. Anticoagulants do not affect the neurological assessment or the diagnosis of stroke. They can, however, interfere with the treatment and recovery of hemorrhagic stroke.

Choice D reason: This is incorrect. Anticoagulant therapy will not be started if necessary to enhance cerebral circulation in patients with hemorrhagic stroke. Anticoagulants do not improve the blood flow to the brain, but rather prevent or dissolve clots that may obstruct it. In patients with hemorrhagic stroke, the pro

A. Maintain a flat lying position for 14 hours following the procedure. B. Muscular discomfort is expected after being in a curled position for a period of time. C. Resume oral intake immediately after the procedure. D. Mild pain is expected at the needle insertion site.

Correct Answer is A

Explanation

Choice A reason: Maintaining a flat lying position for 14 hours following the procedure is the highest priority teaching point for the patient who had a lumbar puncture. It helps to prevent cerebrospinal fluid leakage and post-lumbar puncture headache, which can be severe and debilitating.

Choice B reason: Muscular discomfort is expected after being in a curled position for a period of time, but it is not the highest priority teaching point for the patient who had a lumbar puncture. It is a common and mild side effect that can be relieved by analgesics, massage, or heat therapy.

Choice C reason: Resuming oral intake immediately after the procedure is not a priority teaching point for the patient who had a lumbar puncture. It is not contraindicated, but it is not essential either. The patient should drink plenty of fluids to replenish the cerebrospinal fluid and prevent dehydration.

Choice D reason: Mild pain is expected at the needle insertion site, but it is not the highest priority teaching point for the patient who had a lumbar puncture. It is a common and mild side effect that can be relieved by analgesics, ice packs, or dressing.

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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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