An expected outcome that the nurse evaluates a client for after a ...

[tichca]

An expected outcome that the nurse evaluates a client for after a lumbar puncture is:
 
  A. A decrease in the level of consciousness
  B. A postprocedure headache
  C. Tingling in the lower extremities
  D. A - to 1-inch circle of red drainage at the puncture site

Question 2

The nurse is caring for four patients who require medications at 0900 . Which action by the nurse adheres to the six rights of medication administration?
 
  a. Prepare medications for all of the patients at once and keep the cups separate.
  b. Ask the supervisor to clarify an unclear medication order.
  c. Give the prescribed anticonvulsant between 0830 and 0930.
  d. Leave each patient's medications at the bedside and return within 30 minutes to make sure they have been taken.

[popopong]

Answer to Question 1

D
D. Only a small amount (1- to 2-cm circle) ( to 1 inch) of clear or red drainage present at puncture site is expected.
A. Assess level of consciousness, vital signs, pupils, and respiratory status. Changes may indicate complications of brain herniation or irritation of spinal nerves.
B. A postdural headache is an unexpected outcome that may require that the client be medicated.
C. Hematoma at puncture site evidenced by lower extremity tingling is an unexpected outcome.

Answer to Question 2

C
Time-critical medications such as anticonvulsants must be given within 30 minutes of the prescribed time. Prepare medications for one patient at a time. Keep all pages of the MAR for one patient together. This prevents preparation errors. Unclear orders should be clarified with the prescriber before administration. Stay with each patient until the medication is swallowed completely or is taken by the prescribed route.

[tichca]

Excellent

[nothere]

TYSM