Difficulty: Medium
Average Score: 90%
Simulated
Passage / Scenario
Nurses' Notes Day 1, 1020: Child is a direct admit from a pediatric clinic with fever, chills, irritability for 2 days, prior URI 2 weeks ago, no prior conditions, fully immunized. 1030: Child reports nausea, headache (7/10), lethargic, nuchal rigidity, capillary refill 4 seconds.A pediatrician has evaluated the child and has written new prescriptions. The nurse is preparing to assist with a lumbar puncture. Which of the following actions should the nurse take? Select all that apply.
Correct answer
A,D,E,G
Rationale
Correct answer: A, D, E, G
A: Apply pressure to the puncture site following the procedure - This is important to prevent bleeding and promote clotting.
D: Ensure the guardian has signed the consent form prior to the procedure - This is a legal and ethical requirement to ensure informed consent.
E: Ensure the child voids prior to the procedure - This helps reduce the risk of post-procedure urinary retention.
G: Monitor for paresthesia and tingling in extremities following the procedure - This is important to assess for potential nerve damage or complications.
Incorrect choices:
B: Limit the child's fluid intake following the procedure - There is no need to limit fluid intake post-lumbar puncture.
C: Position the child in a prone position during the procedure - The child should be in a lateral decubitus position for a lumbar puncture.
F: Insert an indwelling urinary catheter during the procedure - There is no indication for inserting a catheter
A: Apply pressure to the puncture site following the procedure - This is important to prevent bleeding and promote clotting.
D: Ensure the guardian has signed the consent form prior to the procedure - This is a legal and ethical requirement to ensure informed consent.
E: Ensure the child voids prior to the procedure - This helps reduce the risk of post-procedure urinary retention.
G: Monitor for paresthesia and tingling in extremities following the procedure - This is important to assess for potential nerve damage or complications.
Incorrect choices:
B: Limit the child's fluid intake following the procedure - There is no need to limit fluid intake post-lumbar puncture.
C: Position the child in a prone position during the procedure - The child should be in a lateral decubitus position for a lumbar puncture.
F: Insert an indwelling urinary catheter during the procedure - There is no indication for inserting a catheter