A client with atrial fibrillation is scheduled for an elective cardioversion.

The nurse prepares for the procedure by inserting two intravenous (IV) catheters and connecting the monitoring lead wires to the client.
Which action is most crucial for the nurse to take before initiating the cardioversion?

Choice A rationale
Testing the fluid on the dressing for glucose is the immediate action the nurse should take. Clear fluid could be cerebrospinal fluid (CSF), which is often released following spinal surgery. CSF contains glucose, so a positive glucose test would confirm it is CSF.
Choice B rationale
Replacing the dressing using a compression bandage is not the immediate action the nurse should take. While it is important to manage the drainage and prevent infection, the nurse first needs to identify what the clear fluid is.
Choice C rationale
Marking the drainage area with a pen and continuing to monitor is not the immediate action the nurse should take. While this can be part of ongoing wound care and monitoring, the nurse first needs to identify what the clear fluid is.

Choice D rationale
Documenting the findings in the electronic medical record is an important step, but it should not be the immediate action. The nurse first needs to identify what the clear fluid is, as it could indicate a complication from the surgery.

Choice A rationale
Replacing the IV site with a smaller gauge is not the most appropriate intervention in this situation. The client’s confusion and picking at the dressing and tape are likely due to the dementia and increased confusion at night, known as “sundowning”. While a smaller gauge might be less noticeable to the client, it does not address the primary issue of the client’s confusion and restlessness at night.

Choice B rationale
Applying soft bilateral wrist restraints might be considered in some situations to prevent a confused client from removing necessary medical devices. However, restraints should be a last resort after all other interventions have been tried because they can increase agitation and confusion, and they pose a risk for injury.
Choice C rationale
Redressing the abdominal incision is the correct choice. The dressing is no longer occlusive, which means it’s not providing a proper barrier to bacteria. This could lead to an infection in the surgical site. The nurse should clean the area and apply a new sterile dressing.
Additionally, the nurse should continue to monitor the client’s behavior and implement interventions to reduce confusion and restlessness, such as reorienting the client and providing a quiet and calm environment.
Choice D rationale
Leaving the lights on in the room at night can actually increase confusion and agitation in clients with dementia. It can disrupt the client’s sleep-wake cycle and make “sundowning” worse. Therefore, this is not the most appropriate intervention.