Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take?
A. Instruct the client to expect tingling in their extremities.
Instructing the client to expect tingling in their extremities is not a standard post-lumbar puncture care instruction. Tingling may be a sign of nerve irritation or damage, which is not an expected outcome and should be reported if it occurs.
B. Measure blood glucose every 2 hours.
Measuring blood glucose every 2 hours is not related to post-lumbar puncture care unless the client has a specific condition that requires such monitoring. Post-lumbar puncture care focuses on preventing complications such as headaches and monitoring for signs of infection or bleeding.
C. Limit the client's fluid intake.
Limiting the client's fluid intake is not advised following a lumbar puncture. In fact, increasing fluid intake can help prevent the occurrence of post-lumbar puncture headaches, which are a common complication. Adequate hydration helps replenish cerebrospinal fluid and reduce headache severity.
D. Instruct the client to lie flat.
Instructing the client to lie flat is the correct action. After a lumbar puncture, it is recommended that the client lies flat for several hours to prevent the leakage of cerebrospinal fluid from the puncture site, which can lead to a spinal headache. Lying flat helps maintain normal cerebrospinal fluid pressure and reduces the risk of headache.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Medical Surgical 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A reason: Instructing the client to expect tingling in their extremities is not a standard post-lumbar puncture care instruction. Tingling may be a sign of nerve irritation or damage, which is not an expected outcome and should be reported if it occurs.
Choice B reason: Measuring blood glucose every 2 hours is not related to post-lumbar puncture care unless the client has a specific condition that requires such monitoring. Post-lumbar puncture care focuses on preventing complications such as headaches and monitoring for signs of infection or bleeding.
Choice C reason: Limiting the client's fluid intake is not advised following a lumbar puncture. In fact, increasing fluid intake can help prevent the occurrence of post-lumbar puncture headaches, which are a common complication. Adequate hydration helps replenish cerebrospinal fluid and reduce headache severity.
Choice D reason: Instructing the client to lie flat is the correct action. After a lumbar puncture, it is recommended that the client lies flat for several hours to prevent the leakage of cerebrospinal fluid from the puncture site, which can lead to a spinal headache. Lying flat helps maintain normal cerebrospinal fluid pressure and reduces the risk of headache.
Similar Questions
A nurse is caring for a client who is postoperative following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
A. Muscle twitching
Muscle twitching can be indicative of hypocalcemia, a common and serious complication following a complete thyroidectomy due to potential damage or removal of the parathyroid glands. Hypocalcemia requires immediate intervention to prevent more severe symptoms such as tetany or cardiac complications.
B. Client report of nausea
While nausea is a common postoperative symptom, it is not typically as urgent as signs of hypocalcemia. However, persistent nausea should still be addressed as it can affect the client's comfort and nutritional intake.
C. Serosanguineous drainage
Serosanguineous drainage is expected to some extent after surgery, but if it is excessive or changes in character, it may indicate hemorrhage or infection, which would then become a priority.
D. Client report of incisional pain
Incisional pain is also expected postoperatively. While pain management is important for recovery, it is not as immediately concerning as potential hypocalcemia unless the pain is severe or uncontrolled, suggesting complications.
Full Explanation
Choice A reason : Muscle twitching can be indicative of hypocalcemia, a common and serious complication following a complete thyroidectomy due to potential damage or removal of the parathyroid glands. Hypocalcemia requires immediate intervention to prevent more severe symptoms such as tetany or cardiac complications.
Choice B reason : While nausea is a common postoperative symptom, it is not typically as urgent as signs of hypocalcemia. However, persistent nausea should still be addressed as it can affect the client's comfort and nutritional intake.
Choice C reason : Serosanguineous drainage is expected to some extent after surgery, but if it is excessive or changes in character, it may indicate hemorrhage or infection, which would then become a priority.
Choice D reason : Incisional pain is also expected postoperatively. While pain management is important for recovery, it is not as immediately concerning as potential hypocalcemia unless the pain is severe or uncontrolled, suggesting complications.
A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hours. Which of the following actions should the nurse take?
A. Administer prescribed corticosteroids.
Administering corticosteroids is not the first-line action for dyspnea related to fluid overload or other causes of respiratory distress in this context.
B. Slow infusion rate and contact the provider.
Slowing the infusion rate is appropriate when there are signs of fluid overload, such as dyspnea and hypertension. Contacting the provider is crucial for further assessment and management, which may include diuretics or other interventions.
C. Lower the head of the bed to semi-Fowler's.
Lowering the head of the bed to semi-Fowler's may provide some relief for dyspnea, but it does not address the potential cause, which in this case could be fluid overload.
D. Change infusion to lactated Ringer's and maintain rate.
Changing the infusion to lactated Ringer's would not be appropriate if the client is experiencing symptoms of fluid overload. The type of fluid is less important than the volume and rate of administration in this scenario.
Full Explanation
Choice A reason : Administering corticosteroids is not the first-line action for dyspnea related to fluid overload or other causes of respiratory distress in this context.
Choice B reason : Slowing the infusion rate is appropriate when there are signs of fluid overload, such as dyspnea and hypertension. Contacting the provider is crucial for further assessment and management, which may include diuretics or other interventions.
Choice C reason : Lowering the head of the bed to semi-Fowler's may provide some relief for dyspnea, but it does not address the potential cause, which in this case could be fluid overload.
Choice D reason : Changing the infusion to lactated Ringer's would not be appropriate if the client is experiencing symptoms of fluid overload. The type of fluid is less important than the volume and rate of administration in this scenario.
A nurse is assessing a client who has heart failure and a new prescription for metoprolol. Which of the following findings should the nurse identify as an adverse effect of the medication?
A. Blood pressure 138/76 mm Hg
A blood pressure of 138/76 mm Hg is within the higher range of normal and is not typically considered an adverse effect of metoprolol, which is used to lower blood pressure.
B. Temperature 36.3°C (97.3°F)
A temperature of 36.3°C (97.3°F) is within the normal range and is not an adverse effect of metoprolol.
C. Heart rate 48/min
A heart rate of 48/min is considered bradycardia and can be an adverse effect of metoprolol, which is a beta-blocker that can slow down the heart rate.
D. Respiratory rate 10/min
A respiratory rate of 10/min is on the lower end of the normal range but is not a typical adverse effect of metoprolol. However, if the patient shows signs of respiratory distress, it should be addressed.
Full Explanation
Choice A reason : A blood pressure of 138/76 mm Hg is within the higher range of normal and is not typically considered an adverse effect of metoprolol, which is used to lower blood pressure.
Choice B reason : A temperature of 36.3°C (97.3°F) is within the normal range and is not an adverse effect of metoprolol.
Choice C reason : A heart rate of 48/min is considered bradycardia and can be an adverse effect of metoprolol, which is a beta-blocker that can slow down the heart rate.
Choice D reason : A respiratory rate of 10/min is on the lower end of the normal range but is not a typical adverse effect of metoprolol. However, if the patient shows signs of respiratory distress, it should be addressed.