After a lumbar puncture, the nurse should place the client in:

Correct Answer: A

Rationale: The correct answer is A: Supine position with a pillow. Placing the client in a supine position with a pillow helps prevent post-lumbar puncture headache by aiding in the restoration of normal cerebrospinal fluid pressure. The pillow supports the head and neck, reducing strain on the puncture site. Choice B: Supine with neck hyperextended is incorrect as it can increase the risk of complications and discomfort for the client. Choice C: Prone for 24 hours is incorrect as it can lead to increased pressure on the puncture site and hinder the recovery process. Choice D: Orthopneic is incorrect as this position is typically used for respiratory distress and not indicated post-lumbar puncture.

Correct Answer: C

Rationale: The correct answer is C: Droplet isolation precaution. This is because droplet precautions are used to prevent the spread of infectious agents that are transmitted through respiratory droplets. In this scenario, the client must wear a surgical mask when outside the room to prevent the spread of droplets containing pathogens to others. A: Airborne precautions are used for pathogens that can be transmitted through the air over long distances, such as tuberculosis. B: Contact precautions are used for direct contact with the client or their environment to prevent the spread of pathogens. D: Standard precautions are used for all clients to prevent the spread of infection through contact with blood, body fluids, or contaminated surfaces.

Correct Answer: C

Rationale: The correct answer is C: Sitting position. Placing the client in a sitting position during an abdominal paracentesis allows for easier access to the abdomen and minimizes the risk of complications such as lightheadedness or hypotension. This position also promotes optimal drainage of ascitic fluid. A: Supine position is not ideal as it may not provide optimal access to the abdomen for the procedure. B: Left lateral position with legs flexed may not be appropriate as it can hinder access to the abdomen and fluid drainage. D: Right side-lying position is not recommended as it may obstruct access to the abdomen and make the procedure more challenging.

Correct Answer: D

Rationale: The correct answer is D: Auscultate the chest for change or clearing in adventitious breath sounds. This method is the best way to evaluate the effectiveness of tracheal suctioning because it directly assesses the patient's respiratory status. By auscultating the chest, the nurse can listen for any changes in breath sounds, such as clearing of adventitious sounds, indicating improved airway clearance. This objective assessment provides concrete evidence of the intervention's impact on the patient's respiratory function. Incorrect answers: A: Note subjective data such as "My breathing is much improved now." Subjective data rely on the patient's perception and may not always accurately reflect the actual physiological changes. C: Note objective findings such as decreased respiratory rate and pulse. While these are important vital signs, they may not directly indicate the effectiveness of tracheal suctioning in clearing the airway. B: This statement reflects subjective data and does not provide a direct assessment of the patient's respiratory status post-tracheal

Correct Answer: C

Rationale: The most appropriate nursing action when assessing a child complaining of abdominal pain is to avoid painful areas until the end of the assessment (Choice C). This approach helps prevent causing unnecessary discomfort or distress to the child. By starting with non-painful areas, the nurse can establish rapport, gather important information, and assess the child's overall condition before addressing the painful areas. This ensures a thorough and sensitive assessment process. Choice A is incorrect because palpating the most painful area first can cause distress and may not provide a comprehensive assessment. Choice B, palpating for rebound tenderness, is not appropriate as it is more specific to assessing for peritonitis in adults. Choice D, using deep palpation for abdominal tenderness, can be uncomfortable for the child and should be avoided until other assessments have been completed.