Examkin

Soru

Zorluk: KolayBasic Care and Comfort

A client has just returned to the unit after undergoing a lumbar puncture. To promote comfort and minimize the risk of a post-dural puncture headache, which position should the nurse assist the client into?

  1. Supine with the head of the bed flatCevap
  2. B
    Side-lying with the knees drawn tightly up to the chest
  3. C
    High-Fowler's position leaning forward on a bedside table
  4. D
    Semi-Fowler's position with a small pillow under the knees

Cevap

The correct position is supine with the head of the bed flat.
Maintaining a supine position with the head of the bed flat for several hours after a lumbar puncture helps prevent the leakage of cerebrospinal fluid from the puncture site, which is the primary cause of a post-dural puncture headache.

Adım Adım Çözüm

1
Identify the procedure the client just underwent.
The client had a lumbar puncture.
Different procedures require specific post-procedure positioning to prevent distinct complications.
2
Determine the primary risk associated with the immediate post-procedure period for a lumbar puncture.
The main risk is cerebrospinal fluid (CSF) leakage, which leads to a severe post-dural puncture headache.
Understanding the specific complication guides the correct nursing intervention.
3
Select the position that minimizes this fluid leakage.
Keeping the client flat in a supine position prevents gravity from increasing CSF leakage from the spinal puncture site.
This is the standard basic care protocol for minimizing adverse effects following a lumbar puncture.

Anahtar Kavram

Post-procedure positioning for a lumbar puncture requires the client to remain flat to prevent spinal fluid leakage and severe headaches.
Tahmini Süre:45s
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Basic Care and Comfort

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