The registered nurse (RN) and licensed practical nurse (LPN) are caring for several clients. The RN delegates client positioning to the LPN. While evaluating the delegated task, the RN realizes that which client positions require intervention? Select all that apply.

Question

Quizplus · Accepted Answer

A paracentesis requires the client to be upright (semi- to high Fowler) so that fluid accumulates in the lower abdomen where the trocar will be inserted to drain it (Option A). Before lumbar puncture, clients are placed in the side-lying fetal position or hunched seated position to separate the vertebrae. Afterwards, clients remain supine in bed for 4-12 hours to minimize the risk of a post-puncture headache from the loss of cerebrospinal fluid (Option E). Sims position (left side-lying with right hip and knee flexed) is best for enema administration (Option D). (Option B) After a liver biopsy, clients are at risk for internal bleeding due to the vascular nature of the liver. Place clients in the right side-lying position for ≥3 hours afterward to promote direct internal pressure of the liver against itself, which minimizes bleeding. (Option C) After cardiac catheterization via femoral entry, place clients flat or in low Fowler position with the affected extremity straight for about 4-6 hours to avoid pressure at the insertion site and prevent hemorrhage or hematoma. Educational objective: Clients undergoing paracentesis should be upright. After liver biopsy, clients should be in a right side-lying position to prevent hemorrhage. After femoral cardiac catheterization, clients should remain flat. After lumbar puncture, clients should be flat in bed to minimize risk of headache.

The Registered Nurse (RN) and Licensed Practical Nurse (LPN) Are