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 C

Explanation

A. Offer the client oral fluids. Offering fluids is important but is not directly related to turning the client or managing the urinary catheter.
B. Assess the breath sounds. Assessing breath sounds is beyond the scope of practice for a UAP.

C. Empty the urinary drainage bag. This action helps maintain catheter function and reduces the risk of infection by preventing urine from backing up in the bladder.
D. Feed the client a snack. Feeding the client is important but is not related to turning the client or managing the urinary catheter.

A. Begin parenteral antibiotic therapy. B. Administer antiemetic agents. C. Provide a high-calorie, high-protein diet. D. Bivalve the cast for distal compromise.

Correct Answer is A

Explanation

A. Begin parenteral antibiotic therapy.
This is the correct answer. Osteomyelitis is a serious bone infection that requires prompt and aggressive antibiotic therapy to prevent further complications and promote healing.

B. Administer antiemetic agents.
Antiemetic agents may be necessary if the client is experiencing nausea or vomiting, but this is not the priority action.

C. Provide a high-calorie, high-protein diet.
While nutritional support is important for healing, initiating antibiotic therapy to address the infection takes precedence.

D. Bivalve the cast for distal compromise.
Bivalving the cast might be necessary if there is evidence of compartment syndrome or impaired circulation, but there is no indication from the question that such a complication is present at this time.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. Which additional action should the nurse instruct the UAP to take each time the client is turned?

Correct Answer is C

Explanation

An adolescent client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. Which action should the nurse implement next?

Correct Answer is A

Explanation

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