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Zorluk: OrtaBasic Care and Comfort

Following a diagnostic lumbar puncture, a client is transferred back to the acute care unit. The client reports mild tenderness at the lower back puncture site but is currently alert with stable vital signs. Which of the following actions is the most appropriate for the registered nurse to implement?

  1. A
    Raise the head of the bed to a 45-degree angle to facilitate optimal breathing.
  2. B
    Assign a nursing assistant to evaluate the sterile dressing for any clear fluid drainage.
  3. Keep the client strictly in a flat, supine position for the prescribed duration.Cevap
  4. D
    Flex the client's knees and tuck the chin to the chest in a side-lying posture.

Cevap

Keep the client strictly in a flat, supine position for the prescribed duration.
The correct action is to maintain the client in a flat, supine position for several hours following a lumbar puncture. This positioning helps prevent a post-dural puncture headache (often called a spinal headache) by reducing the hydrostatic pressure and preventing the rapid leakage of cerebrospinal fluid from the puncture site.

Adım Adım Çözüm

1
Identify the primary risks following a diagnostic lumbar puncture.
The most common and significant complications are cerebrospinal fluid (CSF) leakage and subsequent post-dural puncture headache (spinal headache).
Understanding the physiological risks allows the nurse to anticipate and implement necessary preventive measures.
2
Determine the optimal positioning to mitigate these risks.
A flat, supine position is required.
Laying flat minimizes hydrostatic pressure on the dural puncture site, reducing the likelihood of CSF leakage and helping to prevent spinal headaches.
3
Evaluate the remaining choices for safety and scope of practice.
Elevating the head or returning to the fetal position increases complication risks, while assigning an assessment to unlicensed personnel violates delegation rules.
Assessments cannot be delegated, and upright or flexed positions are contraindicated post-procedure.

Anahtar Kavram

Post-Lumbar Puncture Care and Positioning
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Konular

Basic Care and Comfort

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