A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best?
a. Ensure that informed consent is on the chart.
b. Document these findings in the client's record.
c. Give the prescribed preprocedure sedation.
d. Notify the provider of the findings immediately.
ANS: D
This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead to herniation. Informed consent is needed for an LP, but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure sedation (or other preprocedure medications) should not be given as the LP will most likely be canceled.
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