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Zorluk: OrtaReduction of Risk Potential

A nurse is caring for a client with suspected *Neisseria meningitidis* who has just returned to the unit following a bedside lumbar puncture. Which of the following nursing actions is most appropriate to minimize the client's risk for post-procedure complications and maintain a safe environment?

  1. Maintain the client in a flat, supine position for 4 to 8 hours and ensure droplet precautions are strictly followed.Cevap
  2. B
    Elevate the head of the bed to 45 degrees to prevent sudden increases in intracranial pressure and initiate airborne precautions.
  3. C
    Delegate the initial post-procedure vital signs and neurological checks to an unlicensed assistive personnel (UAP).
  4. D
    Perform a physical assessment of the client, ensuring to palpate the abdomen for bladder distention prior to auscultating for bowel sounds.

Cevap

Maintain the client in a flat, supine position for 4 to 8 hours and ensure droplet precautions are strictly followed.
The correct answer addresses two critical priorities for this client. Following a lumbar puncture, the client should remain in a flat, supine position for 4 to 8 hours to prevent cerebrospinal fluid (CSF) leakage and minimize the risk of a post-dural puncture headache. Additionally, Neisseria meningitidis is transmitted via large respiratory droplets, requiring the immediate implementation of droplet precautions to maintain environmental safety and prevent transmission to healthcare workers and other clients.

Adım Adım Çözüm

1
Identify the primary physiological risks associated with the immediate post-lumbar puncture period.
The client is at high risk for a cerebrospinal fluid (CSF) leak at the dural puncture site, which can lead to a severe spinal headache.
A puncture in the dura mater allows CSF to escape, especially if hydrostatic pressure increases due to an upright posture.
2
Determine the appropriate client positioning to mitigate this physiological risk.
The client must remain in a flat, supine position for 4 to 8 hours.
This flat positioning equalizes hydrostatic pressure along the spinal column and allows the dural puncture site time to seal off, reducing the risk of CSF leakage.
3
Identify the infection control requirements for suspected Neisseria meningitidis.
Droplet precautions must be implemented.
The pathogen is transmitted through large respiratory droplets, making standard precautions insufficient and airborne precautions unnecessary.

Anahtar Kavram

Reduction of risk potential following a lumbar puncture involves maintaining a flat, supine position to prevent cerebrospinal fluid leakage, combined with appropriate transmission-based precautions for the underlying infectious etiology.
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Reduction of Risk Potential

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