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

The unlicensed assistive personnel (UAP) is providing care to a client with influenza, a respiratory illness that can be transmitted through droplets when the client coughs or sneezes. Therefore, it is crucial for the UAP to wear a face mask while in close contact with the client to prevent the transmission of the virus. This is in line with the standard precautions for infection control, which recommend the use of personal protective equipment (PPE) such as gloves, gowns, and masks when providing care to clients with infectious diseases.
Choice B rationale
Reassigning the UAP to another client and assuming full care of the client is not the most appropriate action in this situation. While it is the nurse’s responsibility to ensure that the UAP is competent and understands the care needs of the client, it is not necessary to reassign the UAP unless there are specific concerns about their ability to provide safe and effective care.
Choice C rationale
While it is important for the UAP to alert the nurse of any changes in the client’s respiratory status, this is not the most immediate action that the nurse should take in this situation. The priority is to ensure that the UAP is wearing appropriate PPE to prevent the transmission of influenza.
Choice D rationale
A fitted respirator mask is typically used when caring for clients with airborne diseases, such as tuberculosis. Influenza is primarily spread through droplets, so a regular face mask is usually sufficient for protection.

A. Reduced level of pain B. Improved visual acuity C. Full volume of pedal pulses D. Granulating tissue in foot ulcer . .

Correct Answer is A

Explanation

Choice A rationale
Pregabalin is a medication used to treat nerve pain, particularly in conditions like diabetic peripheral neuropathy. A reduced level of pain would indicate that the medication is effective.
Choice B rationale
Improved visual acuity is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect vision.
Choice C rationale
Full volume of pedal pulses is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect circulation.
Choice D rationale
Granulating tissue in a foot ulcer is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect wound healing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with influenza requires assistance in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. What action should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is A

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?