Which of the ff. nursing actions prepares a patient for a lumbar puncture?

Correct Answer: B

Rationale: Positioning the patient on their side is a critical nursing action that prepares a patient for a lumbar puncture. This position is usually used during the procedure to allow easier access to the lumbar region. Placing the patient on their side helps provide better visualization of the spinal landmarks and facilitates the correct positioning of the needle for the lumbar puncture. This position also helps minimize the risk of complications and ensures the safety and comfort of the patient during the procedure. Administering enemas until clear, removing all metal jewelry, and removing the patient's dentures are not specifically associated with preparing a patient for a lumbar puncture.

Correct Answer: C

Rationale: Nephrosis in children is also known as nephrotic syndrome, which is characterized by the presence of albuminuria (loss of protein in the urine), hypoproteinemia (low levels of protein in the blood), and edema (swelling due to fluid retention). This condition results from damage to the filters in the kidneys, leading to increased permeability and loss of protein in the urine. The classic triad of symptoms in nephrotic syndrome includes proteinuria, hypoalbuminemia, and edema. Other symptoms may include weight gain, frothy urine, and susceptibility to infections. Hematuria, hyperlipidemia, and hypertension are not typical features of nephrotic syndrome in children.

Correct Answer: D

Rationale: A hemolytic reaction is the most likely problem associated with blood transfusion. A hemolytic reaction occurs when the body's immune system attacks the transfused blood, leading to the destruction of red blood cells. This reaction can cause serious complications, including kidney damage, shock, and even death. It is crucial for healthcare providers to carefully match blood types and perform compatibility testing before administering a blood transfusion to minimize the risk of a hemolytic reaction. Serum hepatitis, pulmonary edema, and allergic responses are potential complications of blood transfusions, but hemolytic reactions pose the most immediate and severe threat to the patient's health.

Correct Answer: C

Rationale: The precaution a nurse should take to minimize the risk of deaths occurring when potassium chloride is used incorrectly to flush a lock or central venous catheter is to read labels carefully on vials containing flush solutions for locks. This is essential to ensure that the correct solution is being used and to prevent accidental administration of potassium chloride, which can be fatal if used inappropriately. By carefully checking the labels, the nurse can confirm that they are using the correct flush solution and avoid any harmful errors. This simple precaution can help in ensuring patient safety and preventing adverse outcomes.

Correct Answer: B

Rationale: Giving Mr. Franco frequent mouth care is important to remove dried blood when the tongue is bitten during a seizure. Seizures can cause involuntary biting of the tongue, leading to the accumulation of dried blood in the mouth. If this blood is not removed promptly, it can result in discomfort, infection, and potential complications. Regular oral care helps maintain oral hygiene and prevents any issues related to oral trauma during seizures, promoting overall health and well-being for the patient.