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NurseDive Free Nursing Practice Question
A nurse is caring for a toddler who is scheduled to have a lumbar puncture.
Which of the following actions should the nurse take?
A. Restrain the toddler for 1 hr after the procedure.
Restrain the toddler for 1 hr after the procedure. Restraint of a toddler after a lumbar puncture is not a recommended practice. It can be distressing for the child and may not be necessary if appropriate positioning and comfort measures are employed. Restraint is not the correct choice in this situation.
B. Place the toddler in a side-lying, knee-chest position.
Place the toddler in a side-lying, knee-chest position. The correct choice is to place the toddler in a side-lying, knee-chest position for a lumbar puncture. This position allows for proper alignment of the spine and easy access to the lumbar area while minimizing discomfort and risk. It is a standard practice for performing lumbar punctures in pediatric patients, making choice B the correct answer.
C. Ask another nurse to assist with holding the toddler in a prone position.
Ask another nurse to assist with holding the toddler in a prone position. Placing a toddler in a prone position for a lumbar puncture is not the standard practice. It can be challenging to achieve the proper positioning and may not be comfortable or safe for the child. The prone position is not recommended for lumbar punctures, making choice C incorrect.
D. Swaddle the toddler in a warm blanket.
Swaddle the toddler in a warm blanket. Swaddling a toddler in a warm blanket may provide comfort in certain situations but is not the appropriate action for a lumbar puncture. The procedure requires specific positioning to access the lumbar area safely and accurately. Swaddling would not facilitate this positioning and would not be the correct choice.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom T1 PM Summer 2023 Proctored Exam 5. Take the full exam now
Similar Questions
A nurse is collecting data on a client who received an opioid narcotic for incisional pain.
Which of the following findings is the priority?
A. Pulse oximetry.
Pulse oximetry. Pulse oximetry is the top priority in this situation. Opioid narcotics can cause respiratory depression, which can lead to decreased oxygen saturation in the blood. Monitoring oxygen saturation through pulse oximetry allows the nurse to quickly assess the client's respiratory status and intervene if oxygen levels drop below an acceptable range. Ensuring adequate oxygenation is crucial for the client's safety, making choice A the correct answer.
B. Blood pressure.
Blood pressure. Monitoring blood pressure is important when assessing a client's overall condition and response to medications. However, in the context of a client who received an opioid narcotic for incisional pain, monitoring blood pressure is not the top priority. Opioid narcotics primarily affect respiratory and central nervous system function, making respiratory and sedation assessment more critical in this scenario.
C. Level of sedation.
Level of sedation. Assessing the level of sedation is important when a client has received an opioid narcotic, as opioids can cause respiratory depression and sedation. However, in this case, the client received the opioid for incisional pain, and the priority is to ensure adequate oxygenation and respiratory function. Therefore, assessing sedation level, while important, is not the top priority.
D. Pain level.
Pain level. Assessing the client's pain level is important, but it is not the top priority in this scenario. The client received an opioid narcotic for incisional pain, and the primary concern now is to monitor for potential side effects of the medication, such as respiratory depression. Pain assessment should still be done, but it is not the priority.
A nurse is collecting data on a client following administration of an opioid narcotic.
Which of the following findings indicates a decrease in the client's pain?
A. The client is asleep.
The client is asleep. The correct choice is A because the client being asleep can be a significant indicator of pain relief. It suggests that the client is comfortable enough to rest and may not be experiencing severe pain. Opioid narcotics often cause sedation as a side effect, and this sedation can contribute to the client falling asleep. While it is not the only indicator of pain relief, it is a valuable sign to consider in assessing the effectiveness of pain management.
B. The client has an elevated blood pressure.
The client has an elevated blood pressure. An elevated blood pressure may be a response to pain or other stressors. While monitoring blood pressure is important, it is not the primary indicator of pain relief in this context. Opioid narcotics can cause changes in blood pressure, and pain relief can sometimes lead to a decrease in blood pressure. Therefore, an elevated blood pressure alone does not necessarily indicate a decrease in pain.
C. The client has an increased respiratory rate.
The client has an increased respiratory rate. An increased respiratory rate may be a response to pain or distress. However, it is not a reliable indicator of pain relief when a client has received an opioid narcotic. Opioids can depress the respiratory rate, and an increased respiratory rate may persist even after pain relief is achieved. Therefore, an increased respiratory rate alone does not necessarily indicate a decrease in pain.
D. The client is diaphoretic.
The client is diaphoretic. Diaphoresis (excessive sweating) can occur for various reasons, including pain, fever, anxiety, or side effects of medications. While it is essential to assess for signs of discomfort or distress, diaphoresis alone is not a specific indicator of pain relief. It is possible for a client to be diaphoretic even when pain relief has been achieved.
A nurse is calculating the protein needs of a client who is a physical trainer.
The client weighs 220 lb and requires an increase of protein by 2.0 g/kg/day.
The client has taken 0.8 g of protein/kg/day in the past.
How much total protein/day should the nurse recommend?
A. 80 g of protein/day.
This choice suggests that the client needs 80 g of protein/day. However, this is not correct because the client’s weight is 220 lb (which is approximately 100 kg), and they require an increase of protein by 2.0 g/kg/day. This means they need an additional 200 g of protein per day. Adding this to their past intake of 0.8 g/kg/day (which is 80 g/day), the total comes to 280 g/day.
B. 120 g of protein/day.
This choice suggests that the client needs 120 g of protein/day. The client’s total protein requirement per day is more than this.
C. 280 g of protein/day.
Given: - The client's weight is 220 lb. - The client requires an increase of protein by 2.0 g/kg/day. - The client has taken 0.8 g of protein/kg/day in the past. We know that 1 kg = 2.2 lbs. So, we first need to convert the client's weight from lbs to kg. Step 1: Convert the client's weight from lbs to kg 220 lb ÷ 2.2 lb/kg = 100 kg Next, we calculate the increased protein requirement. Step 2: Calculate the increased protein requirement 100 kg × 2.0 g/kg/day = 200 g/day Then, we calculate the past protein intake in g/day. Step 3: Calculate the past protein intake 100 kg × 0.8 g/kg/day = 80 g/day Finally, we add the past protein intake to the increased protein requirement to get the total protein/day the nurse should recommend. Step 4: Calculate the total protein/day 200 g/day + 80 g/day = 280 g/day
D. 400 g of protein/day.
This choice suggests that the client needs 400 g of protein/day. However, this is not correct because it exceeds the client’s total protein requirement per day, which is 280 g/day.
Full Explanation
The correct answer is © 280 g of protein/day.
Choice A reason: This choice suggests that the client needs 80 g of protein/day. However, this is not correct because the client’s weight is 220 lb (which is approximately 100 kg), and they require an increase of protein by 2.0 g/kg/day. This means they need an additional 200 g of protein per day. Adding this to their past intake of 0.8 g/kg/day (which is 80 g/day), the total comes to 280 g/day.
Choice B reason: This choice suggests that the client needs 120 g of protein/day. The client’s total protein requirement per day is more than this.
Choice C reason:
Given:
- The client's weight is 220 lb.
- The client requires an increase of protein by 2.0 g/kg/day.
- The client has taken 0.8 g of protein/kg/day in the past.
We know that 1 kg = 2.2 lbs. So, we first need to convert the client's weight from lbs to kg.
Step 1: Convert the client's weight from lbs to kg
220 lb ÷ 2.2 lb/kg = 100 kg
Next, we calculate the increased protein requirement.
Step 2: Calculate the increased protein requirement
100 kg × 2.0 g/kg/day = 200 g/day
Then, we calculate the past protein intake in g/day.
Step 3: Calculate the past protein intake
100 kg × 0.8 g/kg/day = 80 g/day
Finally, we add the past protein intake to the increased protein requirement to get the total protein/day the nurse should recommend.
Step 4: Calculate the total protein/day
200 g/day + 80 g/day = 280 g/day
Choice D reason: This choice suggests that the client needs 400 g of protein/day. However, this is not correct because it exceeds the client’s total protein requirement per day, which is 280 g/day.