NCLEX-RN

Category - Reduction of Risk

A nurse is caring for a client who had a lumbar puncture. Which of the following findings, when noted, should be reported to the physician immediately as it indicates a serious adverse reaction to the procedure?
  1. PR = 98 bpm
  2. Headache
  3. Hematoma at the puncture site
  4. Pain over the puncture site
Explanation
Answer: C - Hematoma at the puncture site means that there is bleeding. Headache is a common side effect of lumbar puncture that can be prevented by keeping the client flat on the bed for 8-12 hours post-procedure. Pain is expected unless it persists and worsens.
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