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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Correct Answer is ["A","D","E"]

Explanation

Choice A rationale
Sudden onset of confusion in an older adult could be a sign of a urinary tract infection (UTI). UTIs can cause delirium and behavioral changes in older adults. Therefore, asking if the client is experiencing any pain with urination could help identify a potential UTI.
Choice B rationale
While high protein foods are generally beneficial for health, there is no direct link between increased intake of high protein foods and sudden onset of confusion. Therefore, this option is not the most appropriate action in this situation.
Choice C rationale
Reviewing the client’s current food and medication allergies is always important in healthcare settings. However, it may not directly address the sudden onset of confusion unless the client has had a recent change in diet or medication that could have triggered an allergic reaction leading to confusion.
Choice D rationale
A recent fall could potentially cause a sudden change in mental status due to a head injury or other trauma. Therefore, determining if the client has recently experienced a fall is an appropriate action.
Choice E rationale
Fever can cause confusion, especially in older adults. Therefore, providing instruction on taking the client’s temperature can help the caregiver monitor for signs of infection that could be contributing to the client’s confusion.

A. Color, clarity, and odor of urine. B. Patient’s ability to increase fluid intake. C. Patient allergies to antiseptic solutions. D. Previous history of urinary tract infections.

Correct Answer is C

Explanation

Choice A rationale
While the color, clarity, and odor of urine can provide important information about a patient’s overall health and hydration status, it is not the most crucial information to obtain before inserting an indwelling urinary catheter.
Choice B rationale
The patient’s ability to increase fluid intake can be important in managing various health conditions, but it is not the most important information to obtain before this procedure.
Choice C rationale
Knowing if a patient has allergies to antiseptic solutions is crucial before inserting an indwelling urinary catheter. Using an antiseptic solution that a patient is allergic to can lead to serious complications.
Choice D rationale
While a previous history of urinary tract infections can inform the care and management of a patient with an indwelling urinary catheter, it is not the most important information to obtain before the procedure.

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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

Correct Answer is ["A","D","E"]

Explanation

Before inserting an indwelling urinary catheter, which information about the patient is most important for the nurse to obtain?

Correct Answer is C

Explanation

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

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