The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

Test the fluid on the dressing for glucose.

Mark the drainage area with a pen and continue to monitor.

Change the dressing using a compression bandage.

Document the findings in the electronic medical record.

Answer and Explanation

The Correct Answer is A

A. Test the fluid on the dressing for glucose.
This is the correct action. Clear fluid on a dressing after lumbar spinal surgery could indicate a cerebrospinal fluid (CSF) leak. Testing the fluid for glucose is essential because CSF contains glucose, whereas normal wound drainage does not. A positive glucose test would confirm the presence of CSF, indicating a potential complication that requires immediate medical attention.

B. Mark the drainage area with a pen and continue to monitor.
While monitoring the size of the drainage area can be useful, it is not the immediate priority. The nurse should first determine whether the clear fluid is CSF.

C. Change the dressing using a compression bandage.
Changing the dressing might be necessary, but using a compression bandage without first identifying the nature of the fluid could be inappropriate and potentially harmful if the fluid is CSF.

D. Document the findings in the electronic medical record.
Documentation is important, but it is not the immediate action. The nurse needs to identify the nature of the fluid first.

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

Explanation

A. Humidifier bottle

Rationale: A humidifier bottle is often used with oxygen therapy to add moisture to the oxygen, preventing dryness of the nasal passages and throat. It is important for patient comfort, especially when oxygen is administered at higher flow rates for prolonged periods.

B. Lamb's wool

Rationale: Lamb's wool is not needed for starting oxygen therapy. It is typically used to provide padding and comfort in other situations, such as preventing pressure sores, but it has no role in the administration of oxygen.

C. Flowmeter

Rationale: A flowmeter is necessary to regulate the flow rate of oxygen. It ensures that the client receives the prescribed amount of oxygen (3 L/minute in this case), making it an essential component for administering oxygen therapy.

D. Tape

Rationale: Tape is not required for administering oxygen via a nasal cannula. It might be used to secure tubing in other contexts, but it is not specifically needed for starting oxygen therapy. The nasal cannula usually stays in place without the need for tape.

E. Suction cannister

Rationale: A suction canister is used in suctioning procedures to collect secretions and is not needed for starting oxygen therapy. It is relevant for managing airway secretions but unrelated to the administration of oxygen.

F. Nasal cannula

Rationale: A nasal cannula is the device through which oxygen is delivered to the client. It is specifically mentioned in the order and is essential for administering the oxygen.

G. Sterile water

Rationale: Sterile water is used to fill the humidifier bottle to provide humidified oxygen. This helps to prevent the drying effects of oxygen therapy on the mucous membranes, enhancing patient comfort.

A. Administer oxygen 5 L/minute via simple face mask B. Bacitracin applied topically to lacerations every 12 hours C. Place 2 large bore peripheral IV's D. X-ray of the right arm and cervical spin E. Computed tomography scan of the brain F. Vital signs ever 1 hour G. Give 1 Liter bolus of 0.9% sodium chloride solution IV once

Correct Answer is ["A","C","G"]

Explanation

A. Administer oxygen 5 L/minute via simple face mask: Oxygen administration is a priority intervention to improve oxygenation and address the client's low oxygen saturation of 82%.
Hypoxemia can lead to tissue hypoxia and further compromise the client's condition. Therefore, administering oxygen should be the first action taken to ensure an adequate oxygen supply to vital organs.
B. Bacitracin applied topically to lacerations every 12 hours: While wound care is important, administering oxygen and establishing IV access take precedence over topical
treatment. Oxygenation and fluid resuscitation are critical in the immediate management of a trauma patient to ensure adequate tissue perfusion and oxygen delivery.

C. Place 2 large bore peripheral IV's: Establishing IV access is essential for administering medications and fluids rapidly. This is particularly important in this scenario where the client may require immediate fluid resuscitation due to hypotension (blood pressure of 83/41 mm Hg).
Large bore IV access allows for rapid infusion of fluids and medications to stabilize the client's hemodynamic status.

D. X-ray of the right arm and cervical spine: While diagnostic imaging is important for assessing injuries, it is not as urgent as administering oxygen and establishing IV access. Oxygenation and fluid resuscitation are higher priorities to stabilize the client's condition before proceeding with diagnostic tests.

E. Computed tomography scan of the brain: While a CT scan of the brain is essential for assessing potential head injuries, the immediate focus should be on stabilizing the client's oxygenation and hemodynamic status. Administering oxygen and fluids take precedence over diagnostic imaging to address the client's hypoxemia and hypotension.

F. Vital signs every 1 hour: Monitoring vital signs is important for ongoing assessment, but it is not as urgent as administering oxygen and fluids. Vital signs should be monitored closely, but immediate interventions to address hypoxemia and hypovolemia are critical to stabilize the client's condition.

G. Give 1 Liter bolus of 0.9% sodium chloride solution IV once: The client's hypotension (blood pressure of 83/41 mm Hg) indicates hypovolemia and the need for fluid resuscitation. Administering a bolus of intravenous fluids (1 Liter bolus of 0.9% sodium chloride solution) is essential to address hypovolemia and improve perfusion to vital organs. This intervention helps stabilize the client's blood pressure and prevent further deterioration of her condition.

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The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits To start the client on oxygen as ordered, what item(s) should the nurse collect from the supply room? Select all that apply.

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

Explanation

Correct Answer is ["A","C","G"]

Explanation

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