Which instruction should the practical nurse (PN) provide the unlicensed assistive personnel (UAP) assisting with the care of a client following a lumbar puncture?
Explanation & Rationale
A. "Be sure to keep the client supplied with plenty of fluids.": While hydration after a lumbar puncture helps reduce the risk of post-procedure headache, encouraging or monitoring fluid intake is part of routine nursing care and does not require delegation to the UAP as a primary instruction. B. "It is important to monitor the appearance of the puncture site.": Assessment of the puncture site for drainage, redness, or swelling requires nursing judgment and should be performed by the PN or RN, not delegated to the UAP. C. "Let me know if there is a significant change in the vital signs.": The UAP can accurately measure and report vital signs. Sudden changes, such as hypotension or tachycardia, may indicate complications like cerebrospinal fluid leakage or bleeding, requiring prompt nurse evaluation. D. "Report any change in the client's distal circulation checks.": Circulatory checks are not typically indicated following a lumbar puncture because the procedure does not affect limb perfusion; therefore, this instruction is not relevant to the client’s condition.