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Question

Difficulty: EasyReduction of Risk Potential

A client arrives at the medical unit after undergoing a diagnostic lumbar puncture. To decrease the risk of a post-dural puncture headache, which action is most important for the nurse to implement?

  1. A
    Place the client in a high-Fowler's position to facilitate respiration.
  2. B
    Position the client in a side-lying fetal position.
  3. Ensure the client remains in a flat, supine position for several hours.Answer
  4. D
    Encourage the client to sit upright in a chair at the bedside.

Answer

Ensure the client remains in a flat, supine position for several hours.
Following a lumbar puncture, keeping the client flat and supine for several hours is a standard intervention. This position minimizes the pressure on the dural puncture site, significantly reducing the risk of cerebrospinal fluid (CSF) leakage and the development of a painful post-dural puncture headache.

Step-by-Step Solution

1
Identify the procedure performed and its common complications.
The client had a lumbar puncture, which carries a high risk for a post-dural puncture headache due to cerebrospinal fluid (CSF) leakage.
Recognizing procedure-specific risks is essential for determining appropriate post-procedure care.
2
Determine the appropriate nursing intervention to prevent the complication.
Maintaining a flat, supine position is required to equalize pressure and minimize CSF leakage from the puncture site.
Gravity increases the pressure on the dural puncture site when the client is upright, leading to fluid loss and subsequent headaches.

Key Concept

Post-lumbar puncture positioning to prevent complications
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Topics

Reduction of Risk Potential

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