The nurse is assisting the health care provider collect cerebrospinal fluid for testing to rule out meningitis. Which are the nurse's responsibilities?
1. Explain the procedure and obtain signed consent.
2. Teach the client how to assist during the procedure by maintaining proper positioning.
3. Observe sterile technique when preparing the equipment for the procedure.
4. Label all specimens collected and send them to the lab.
5. Assess the client before, during, and after the procedure.
2, 3, 4, 5
Rationale 1: The nurse does not explain the procedure prior to obtaining the consent; this is the role of the health care provider. The nurse may witness the signature if the client does not have questions.
Rationale 2: The client should be taught how to maintain proper positioning during the procedure to prevent complications.
Rationale 3: The nurse observes sterile technique when setting up the sterile tray in preparation for the procedure.
Rationale 4: Once the fluid has been collected, all tubes should be properly labeled and sent to the lab. Although the nurse may delegate this to the unlicensed assistive personnel, the nurse is responsible.
Rationale 5: The nurse's primary responsibility is to monitor the client's condition before, during, and after the procedure.
Global Rationale: The nurse does not explain the procedure prior to obtaining the consent; this is the role of the health care provider. The nurse may witness the signature if the client does not have questions. The client should be taught how to maintain proper positioning during the procedure to prevent complications. Once the fluid has been collected, all tubes should be properly labeled and sent to the lab. Although the nurse may delegate this to the unlicensed assistive personnel, the nurse is responsible. The nurse's primary responsibility is to monitor the client's condition before, during, and after the procedure. The nurse also observes sterile technique when setting up the sterile tray in preparation for the procedure.
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