Published Jun 7, 2013
swansonplace
789 Posts
While running a mountainous marathon, a runner falls over a cliff and hits her head. The runner is admitted to the local hospital. The physician asks the nurse to prepare the client for a lumbar puncture. Which of the following actions should the nurse take FIRST?
[TABLE=class: interaction]
[TR=class: answerChoiceRow selectedansstyle]
[TD][/TD]
[TD]1. [/TD]
[TD=class: choiceContent]Obtain informed consent.[/TD]
[/TR]
[TR=class: answerChoiceRow]
[TD]2. [/TD]
[TD=class: choiceContent correctanswerhighlight1] Obtain the client's vital signs. [/TD]
[TD]3. [/TD]
[TD=class: choiceContent]Explain procedure to client. [/TD]
[TD]4. [/TD]
[TD=class: choiceContent]Procure lumbar puncture tray. [/TD]
[/TABLE]
Strategy: "FIRST" indicates priority.
1) responsibility of the physician
2) CORRECT-- change in vital signs could indicate increased intracranial pressure (ICP), which is contraindicated in lumbar puncture
3) physical needs take priority over psychosocial needs
4) priority is completing the assessment
Can you explain why answer one is incorrect. Get informed consent. That is shouldn't the nurse get informed consent first.
monicaa_rn
41 Posts
No, it's the physician's responsibility to obtain informed consent. RN can witness.
Use your ABC's.. the answer is #2
BorgQueen1701
110 Posts
Its the nurses responsibility to Witness the consent being signed, and make sure that it is attached the file. The physician is responsible for 'obtaining' it. This is straight from a Kaplan video I just watched today.
manavhinta
14 Posts
it is a priority question as u can see the word FIRST .....so no 1 is not wrong its just not the priority at this time vital signs show any abnormal response in pts condition prior to lumbar punture..........
Thanks.