The nurse notices the presence of clear fluid on the surgical dressing of a patient who has just returned to the unit following lumbar spinal surgery.
What immediate action should the nurse take?

Test the fluid on the dressing for glucose.

Replace the dressing using a compression bandage.

Mark the drainage area with a pen and continue monitoring.

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 action the nurse should take. Clear fluid could be cerebrospinal fluid (CSF), which is often released following spinal surgery. CSF contains glucose, so a positive glucose test would confirm it is CSF.
Choice B rationale
Replacing the dressing using a compression bandage is not the immediate action the nurse should take. While it is important to manage the drainage and prevent infection, the nurse first needs to identify what the clear fluid is.
Choice C rationale
Marking the drainage area with a pen and continuing to monitor is not the immediate action the nurse should take. While this can be part of ongoing wound care and monitoring, the nurse first needs to identify what the clear fluid is.

Choice D rationale
Documenting the findings in the electronic medical record is an important step, but it should not be the immediate action. The nurse first needs to identify what the clear fluid is, as it could indicate a complication from the surgery.

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Correct Answer is A

Explanation

Choice A rationale
In a client with gastroenteritis experiencing fever, chills, anorexia, and diarrhea, fluid volume deficit is a major concern. Diarrhea and fever can both lead to significant fluid loss. If not addressed, fluid volume deficit can lead to serious complications such as hypovolemic shock.
Choice B rationale
While impaired bed mobility may be a concern due to the client’s history of stroke, it is not the highest priority in this situation. The immediate physiological needs related to the client’s gastroenteritis and potential fluid volume deficit should be addressed first.
Choice C rationale
Caregiver role strain may be a concern given that the client is dependent on care provided by the spouse. However, this psychosocial issue is not the highest priority when the client is experiencing acute physical symptoms that need immediate attention.
Choice D rationale
Bowel incontinence could be a concern for a client with gastroenteritis. However, the risk of fluid volume deficit due to diarrhea and fever is a more immediate concern.

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

Correct Answer is B

Explanation

Choice A rationale
While a high-calorie, high-protein diet can be beneficial for patients recovering from surgery or illness, it is not the immediate next step after collecting bone aspirate specimens for culture and sensitivity and applying a cast to a patient’s lower leg. The priority is to address the infection identified through the bone aspirate specimens.

Choice B rationale
Beginning parenteral antibiotic therapy is the appropriate next step after collecting bone aspirate specimens for culture and sensitivity in a patient with osteomyelitis. Osteomyelitis is an infection in the bone, and antibiotics are typically the first line of treatment. Therefore, this choice is the correct answer.
Choice C rationale
Administering antiemetic agents would be appropriate if the patient were experiencing nausea or vomiting. However, there is no indication in the question that the patient is experiencing these symptoms. Therefore, this choice is not the correct answer.
Choice D rationale
Bivalving the cast for distal compromise would be appropriate if there were signs of compromised circulation or nerve function below the level of the cast. However, there is no indication in the question that the patient is experiencing these issues. Therefore, this choice is not the correct answer.

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The nurse notices the presence of clear fluid on the surgical dressing of a patient who has just returned to the unit following lumbar spinal surgery. What immediate action should the nurse take?

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Correct Answer is A

Explanation

An adolescent patient with a non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. After the healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent’s lower leg, what should the nurse do next?

Correct Answer is B

Explanation

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The nurse notices the presence of clear fluid on the surgical dressing of a patient who has just returned to the unit following lumbar spinal surgery.
What immediate action should the nurse take?