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

Nadolol is a beta-blocker that can decrease heart rate and contractility, which can potentially exacerbate heart failure and lead to cardiogenic shock.

Choice B rationale

Captopril is an angiotensin-converting enzyme (ACE) inhibitor that is often used in the treatment of heart failure. It works by relaxing blood vessels and reducing the workload of the heart.

Choice C rationale

Digoxin is a cardiac glycoside that is used to treat heart failure and certain heart arrhythmias. It works by increasing the force of the heart’s contractions, which can improve heart function.

Choice D rationale

Hydrochlorothiazide is a diuretic that is often used in the treatment of heart failure. It works by helping the body get rid of excess fluid, which can reduce the workload of the heart.

A. Ask if the client is experiencing any pain with urination. B. Encourage increased intake of high protein foods. C. Review the client’s current food and medication allergies. D. Determine if the client has recently experienced a fall. E. Provide instruction on taking the client’s temperature.

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.

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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

The nurse is caring for a client with heart failure. Which of these prescribed medications places the client at risk for cardiogenic shock?

Correct Answer is A

Explanation

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

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?