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Question

Difficulty: MediumReduction of Risk Potential

A charge nurse is conducting safety rounds on a medical-surgical unit and observes the positioning of several clients. Which client positions increase the risk for physiological complications and require immediate intervention by the nurse? (Select all that apply.)

  1. A client who is 2 hours post-lumbar puncture resting in a semi-Fowler's position.Answer
  2. A client receiving continuous enteral tube feedings lying flat in the supine position while receiving a bed bath.Answer
  3. A client who is 48 hours post-above-the-knee amputation with the residual limb continuously elevated on a pillow.Answer
  4. D
    A client with a suspected venous air embolism placed in a left lateral Trendelenburg position.
  5. E
    A client who had a cardiac catheterization via the right femoral artery 4 hours ago, lying flat with the right leg straight.
  6. F
    A client recovering from a supratentorial craniotomy positioned with the head of the bed elevated at 30 degrees.

Answer

The nurse must intervene for the client in a semi-Fowler's position 2 hours post-lumbar puncture, the client receiving continuous enteral feedings while lying flat, and the client with a residual limb elevated on a pillow 48 hours post-amputation.
The correct options represent positions that place the client at immediate risk for severe complications. A client should remain flat (supine) for several hours after a lumbar puncture to prevent cerebrospinal fluid leakage and spinal headaches; semi-Fowler's is contraindicated. Continuous enteral tube feedings require the head of the bed to be elevated at least 30 degrees to prevent aspiration; the feeding must be paused if the client is laid flat for care. Elevating a residual limb on a pillow is acceptable for the first 24 hours to reduce edema, but doing so 48 hours post-amputation significantly increases the risk of developing an irreversible hip flexion contracture.

Step-by-Step Solution

1
Evaluate each client's position against established safety protocols and the specific physiological risks associated with their recent procedure or medical condition.
Determine which positions are contraindicated and could lead to severe physiological decompensation.
Client positioning is a critical component of risk reduction. Incorrect positioning can directly cause complications such as aspiration, hemorrhage, or structural deformities.
2
Select only the options where the client's current position is harmful and requires the nurse to take immediate corrective action.
The lumbar puncture, continuous tube feeding, and amputation positions are identified as harmful.
These specific positions increase the risk for cerebrospinal fluid leakage, pulmonary aspiration, and hip flexion contractures, respectively.

Key Concept

Therapeutic and Post-Procedure Client Positioning for Risk Reduction
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Topics

Reduction of Risk Potential

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