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Question

Difficulty: EasyReduction of Risk Potential

A nurse is planning care for a client who has just returned to the nursing unit following a lumbar puncture. Which of the following actions should the nurse take to reduce the risk of post-procedure complications?

  1. Maintain the client in a flat, supine position for 4 to 8 hours.Answer
  2. B
    Elevate the head of the bed to a 45-degree angle to promote respiratory expansion.
  3. C
    Prioritize a full musculoskeletal assessment before inspecting the puncture dressing.
  4. D
    Palpate the client's abdomen before auscultating bowel sounds to check for urinary retention.

Answer

Maintain the client in a flat, supine position for 4 to 8 hours.
Following a lumbar puncture, the client is at high risk for developing a spinal headache caused by the leakage of cerebrospinal fluid (CSF) from the puncture site in the dura mater. Maintaining the client in a flat, supine position for a prescribed period (typically 4 to 8 hours) equalizes pressure in the subarachnoid space. This significantly reduces the risk of CSF leakage and subsequent complications, thereby promoting safe physiological adaptation and risk reduction.

Step-by-Step Solution

1
Identify the procedure the client underwent.
The client had a lumbar puncture.
Different diagnostic procedures require specific post-procedure positioning and care to mitigate unique risks.
2
Determine the primary physiological risk associated with the procedure.
The primary immediate risk following a lumbar puncture is the leakage of cerebrospinal fluid (CSF) from the dural puncture site.
Understanding the potential complication allows the nurse to implement targeted risk reduction strategies.
3
Select the appropriate intervention to minimize this risk.
Positioning the client flat and supine is the correct action.
A flat position equalizes CSF pressure, preventing leakage and subsequent spinal headaches.

Key Concept

Post-Lumbar Puncture Positioning and Complication Prevention
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Topics

Reduction of Risk Potential

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