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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","F"]

Explanation

Choice A rationale
Performing a thorough physical assessment is crucial when elder mistreatment is suspected. It helps to identify any signs of physical abuse or neglect.
Choice B rationale
Developing a safety plan is an important step in ensuring the safety of the elder. This plan can include strategies to avoid potential harm and steps to take if the elder feels unsafe.
Choice C rationale

Taking photographs to document the abuse or neglect can provide concrete evidence of the mistreatment. These photographs can be used in investigations and legal proceedings.
Choice F rationale
Completing a comprehensive history is necessary to understand the full context of the elder’s situation. This includes the elder’s health status, living conditions, and the nature of their relationship with the caregiver.
Choice H rationale
Reporting findings to Adult Protective Services is a critical step in addressing elder mistreatment. Adult Protective Services can conduct further investigations and take necessary actions to protect the elder.

A. Monitor for bleeding side effects related to heparin therapy. B. Promote movement to prevent a pulmonary embolism. C. Check blood pressure and heart rate at least every 4 hours. D. Measure the circumference of each calf to assess for leg edema.

Correct Answer is A

Explanation

Choice A rationale
The most crucial intervention for a nurse to include in the care plan of a client with a deep vein thrombosis (DVT) in the left leg who is on a heparin protocol is to monitor for bleeding side effects related to heparin therapy. Heparin is an anticoagulant medication that prevents the formation of blood clots. While it is an effective treatment for DVT, it can also increase the risk of bleeding. Therefore, it is essential for the nurse to closely monitor the client for any signs of bleeding, such as unusual bruising, blood in urine or stool, or bleeding gums.
Choice B rationale
While promoting movement can help prevent a pulmonary embolism (a potential complication of DVT), it is not the most crucial intervention when a client is on a heparin protocol. Excessive movement can potentially dislodge the clot, leading to a pulmonary embolism. Therefore, while movement is important, it should be done under the guidance of a healthcare professional.
Choice C rationale
Checking blood pressure and heart rate at least every 4 hours is a standard nursing intervention for many clients, not just those with DVT. While it is important to monitor these vital signs, it is not the most crucial intervention for a client with DVT on a heparin protocol.
Choice D rationale

Measuring the circumference of each calf can help assess for leg edema, which can be a sign of DVT. However, this is not the most crucial intervention for a client on a heparin protocol. The priority is to monitor for bleeding side effects related to the heparin therapy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

Correct Answer is ["A","B","C","F"]

Explanation

A client with a deep vein thrombosis (DVT) in the left leg is on a heparin protocol. What is the most crucial intervention for the nurse to include in this client’s care plan?

Correct Answer is A

Explanation

An adult patient visits the clinic expressing concern about a lump that appeared on their neck about a week ago. Upon examination, the nurse finds a large, non-tender, hardened left subclavian lymph node without any overlying tissue inflammation. What could these findings indicate?

A nurse is preparing a 50 mL dose of 50% dextrose IV for a patient experiencing insulin shock. What is the best method for administering the medication?

The nurse is monitoring a patient with Cushing’s disease in the post-anesthesia care unit (PACU) following a hypophysectomy. Which intervention is most important for the nurse to include in the patient’s plan of care?

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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?