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Difficulty: HardBasic Care and Comfort

A client is transferred to the medical-surgical unit immediately after undergoing a diagnostic lumbar puncture. Which interventions should the practical nurse implement to ensure safety and promote comfort? Select all that apply.

  1. Maintain the client in a strictly flat, supine position for the prescribed duration.Answer
  2. B
    Elevate the head of the bed to a 45-degree angle to promote optimal respiratory expansion.
  3. Encourage the consumption of oral fluids unless medically contraindicated.Answer
  4. D
    Assign the assistive personnel to conduct the initial assessment of the puncture site for bleeding.
  5. Collect data regarding motor strength and sensory perception in the bilateral lower extremities.Answer

Answer

The correct interventions include maintaining a flat supine position, encouraging oral fluids, and collecting data on lower extremity neurological function.
Following a lumbar puncture, maintaining a flat, supine position is essential to prevent cerebrospinal fluid (CSF) leakage and subsequent spinal headaches. Encouraging oral fluids helps to quickly replenish the lost CSF volume. Additionally, collecting data on lower extremity sensory and motor function is a critical responsibility to detect potential neurological complications, such as hematoma formation compressing the spinal cord.

Step-by-Step Solution

1
Identify the primary physiological risks associated with a lumbar puncture.
The main risks are cerebrospinal fluid (CSF) leakage and subsequent spinal headaches, as well as potential spinal nerve compression.
Understanding the complications drives the appropriate comfort and safety interventions.
2
Determine the proper positioning required to minimize these risks.
The client must remain in a flat, supine position.
A flat position equalizes pressure in the central nervous system and prevents CSF from leaking through the dural puncture site.
3
Identify supportive care measures to replenish fluid volume.
Encouraging oral fluids is a necessary intervention.
Hydration assists the body in replacing the CSF that was removed during the diagnostic test.
4
Differentiate between nursing responsibilities and delegable tasks.
The nurse must personally collect neurological data and inspect the site; this cannot be delegated to assistive personnel.
Initial assessments require a licensed nurse's clinical knowledge to identify early signs of bleeding or nerve damage.

Key Concept

Post-Lumbar Puncture Care and Positioning
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Topics

Basic Care and Comfort

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