A nurse is preparing to assist a healthcare provider with a bedside lumbar puncture for a client admitted with suspected bacterial meningitis. Which nursing actions are appropriate to ensure client safety and prevent procedure-related complications? Select all that apply.
- Verify the client's identity using two approved identifiers prior to the start of the procedure.Answer
- BDelegate the initial post-procedure vital sign assessments to the unlicensed assistive personnel.
- Assist the client into a lateral decubitus position with the knees flexed toward the chest.Answer
- DAdminister a prescribed intravenous sedative through an existing line without verifying compatibility with the infusing fluids.
- EElevate the head of the bed to a high-Fowler's position immediately after the procedure is completed.
- Confirm that a signed informed consent document is present in the client's medical record.Answer
Answer
The correct actions include verifying the client's identity using two identifiers, assisting the client into a lateral decubitus position with knees flexed, and confirming the presence of a signed informed consent document.
Verifying the client's identity and confirming informed consent are essential components of the Universal Protocol to prevent procedural errors. Assisting the client into the lateral decubitus position with knees flexed safely separates the vertebrae, providing clear access for the provider and minimizing the risk of spinal or nerve injury during the lumbar puncture.
Step-by-Step Solution
Key Concept
Procedural safety measures, including Universal Protocol, safe client positioning, and error prevention during medication administration and task delegation.