Which instruction should the practical nurse (PN) provide the unlicensed assistive personnel (UAP) assisting with the care of a client following a lumbar puncture?

"Be sure to keep the client supplied with plenty of fluids."

"It is important to monitor the appearance of the puncture site."

"Let me know if there is a significant change in the vital signs."

"Report any change in the client's distal circulation checks."

Answer and Explanation

The Correct Answer is C

A. "Be sure to keep the client supplied with plenty of fluids.": While hydration after a lumbar puncture helps reduce the risk of post-procedure headache, encouraging or monitoring fluid intake is part of routine nursing care and does not require delegation to the UAP as a primary instruction.

B. "It is important to monitor the appearance of the puncture site.": Assessment of the puncture site for drainage, redness, or swelling requires nursing judgment and should be performed by the PN or RN, not delegated to the UAP.

C. "Let me know if there is a significant change in the vital signs.": The UAP can accurately measure and report vital signs. Sudden changes, such as hypotension or tachycardia, may indicate complications like cerebrospinal fluid leakage or bleeding, requiring prompt nurse evaluation.

D. "Report any change in the client's distal circulation checks.": Circulatory checks are not typically indicated following a lumbar puncture because the procedure does not affect limb perfusion; therefore, this instruction is not relevant to the client’s condition.

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Correct Answer is A

Explanation

A. Mental status: Assessing mental status is essential before administering zolpidem because it is a sedative-hypnotic medication. Evaluating orientation, alertness, and cognitive function helps ensure the client can safely take the medication and reduces the risk of falls, confusion, or respiratory depression.

B. Skin integrity: While skin assessment is important for overall care, it is not directly related to the administration or safety of zolpidem. Skin integrity does not influence the drug’s sedative effects.

C. Body temperature: Monitoring body temperature is not necessary prior to zolpidem administration. Fever or hypothermia does not typically affect the immediate safety or effectiveness of the medication.

D. Bowel sounds: Assessing bowel sounds is unrelated to zolpidem administration. Gastrointestinal function does not influence the drug’s sedative action or the client’s risk for adverse effects.

A. Write an incident report and submit it to the unit manager. B. Try not to listen to the conversation since it is confidential. C. Approach the individuals involved and ask them to stop. D. Tell the client of the UAP's concern for him.

Correct Answer is C

Explanation

A. Write an incident report and submit it to the unit manager: Filing an incident report is appropriate for serious breaches of protocol, but the immediate priority is to stop the inappropriate discussion to protect client confidentiality.

B. Try not to listen to the conversation since it is confidential: Ignoring the conversation does not address the violation of privacy that is occurring. The PN has a professional responsibility to intervene when confidentiality is breached.

C. Approach the individuals involved and ask them to stop: Directly intervening ensures the conversation ceases and reinforces the importance of client confidentiality. Immediate action protects the client’s privacy and maintains professional standards of care.

D. Tell the client of the UAP's concern for him: Sharing details of the conversation with the client would further breach confidentiality and is inappropriate. The PN’s focus should be on stopping the discussion among staff.

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Which instruction should the practical nurse (PN) provide the unlicensed assistive personnel (UAP) assisting with the care of a client following a lumbar puncture?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Before administering zolpidem at bedtime, which client assessment should the practical nurse (PN) complete?

Correct Answer is A

Explanation

The practical nurse (PN) overhears a conversation between an unlicensed assistive personnel (UAP) and another staff member in the hospital cafeteria line concerning a client's reaction to being given a diagnosis of terminal cancer. What is the best nursing action?

Correct Answer is C

Explanation

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