A nurse notices clear fluid on the surgical dressing of a patient who has just returned from lumbar spinal surgery. What should be the nurse’s immediate course of action?
Test the fluid on the dressing for glucose.
Change the dressing using a compression bandage.
Mark the drainage area with a pen and continue to monitor.
Document the findings in the electronic medical record.
The Correct Answer is A
Choice A rationale
Testing the fluid on the dressing for glucose is the immediate course of action when a nurse notices clear fluid on the surgical dressing of a patient who has just returned from lumbar spinal surgery. Clear fluid could be cerebrospinal fluid (CSF), which contains glucose. If the fluid is positive for glucose, it could indicate a CSF leak, which requires immediate medical attention.
Choice B rationale
Changing the dressing using a compression bandage is not the immediate course of action. The source of the fluid needs to be identified first.
Choice C rationale
Marking the drainage area with a pen and continuing to monitor is not the immediate course of action. The source of the fluid needs to be identified first.
Choice D rationale
Documenting the findings in the electronic medical record is important, but it is not the immediate course of action. The source of the fluid needs to be identified first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Restricted activity can help reduce intestinal activity, thereby decreasing inflammation and allowing for tissue healing within the gastrointestinal tract.
Choice B rationale
While controlling diarrhea episodes is an important aspect of managing Crohn’s disease, it is not the primary purpose of activity restriction.
Choice C rationale
Promoting the healing process is a crucial aspect of managing Crohn’s disease. However, the primary purpose of activity restriction is to reduce intestinal activity, which in turn can promote healing.
Choice D rationale
Decreasing abdominal pain is an important aspect of managing Crohn’s disease, but it is not the primary purpose of activity restriction.
Correct Answer is C
Explanation
Choice A rationale
Comparing muscle strength bilaterally is not the most important intervention in this situation. While muscle weakness can be a symptom of hyperkalemia, it is not the most immediate concern. Hyperkalemia can lead to life-threatening cardiac dysrhythmias, which is a more immediate threat to the patient’s life.
Choice B rationale
Observing the color and amount of urine can provide information about the patient’s renal function, which is important in the regulation of potassium. However, this is not the most immediate concern when a patient’s serum potassium level is dangerously high.
Choice C rationale
Determining the apical pulse rate and rhythm is the most important intervention. Hyperkalemia can cause cardiac dysrhythmias, so the nurse should immediately assess the patient’s heart rate and rhythm. The nurse should also place the patient on a cardiac monitor, if not already done, and notify the healthcare provider immediately.
Choice D rationale
Assessing the strength of deep tendon reflexes can provide information about neuromuscular function, which can be affected by hyperkalemia. However, this is not the most immediate concern. The nurse’s priority is to assess and monitor for life-threatening cardiac dysrhythmias.
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