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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
Step 1: Convert the client’s weight from pounds to kg. 1 kg is approximately 2.2 lbs. So, 176 lbs
÷ 2.2 = 80 kg (rounded to the nearest whole number).
Step 2: Calculate the total mg of enoxaparin sodium needed per day. The prescription is for 1.5 mg/kg/day. So, 80 kg × 1.5 mg/kg/day = 120 mg/day.
Step 3: Calculate the mL of enoxaparin sodium needed. The medication is available in a 120 mg/0.8 mL prefilled syringe. So, 120 mg ÷ 120 mg/0.8 mL = 0.8 mL. The nurse should administer 0.8 mL.
Correct Answer is A
Explanation
Choice A rationale
The neonatal screening test, which includes thyroxine (T4) and thyroid-stimulating hormone (TSH) levels, is a routine blood test required by law to screen for metabolic deficiencies. This test helps diagnose thyroid conditions. T4 is a thyroid hormone, and too much or too little of it can indicate an issue with the thyroid. TSH is a hormone your pituitary gland makes. It stimulates your thyroid to produce T4 and T3 (triiodothyronine) hormones. A TSH test is the best way to initially assess thyroid function. In fact, T4 tests more accurately reflect thyroid function when combined with a TSH test. Measuring T4 levels might not be necessary in all thyroid conditions. Other names for a T4 test include: Free thyroxine, Total T4 concentration, Thyroxine screen, Free T4 concentration, Free T4 index (FTI)1.
Choice B rationale
While the T4 and TSH tests can help diagnose thyroid conditions, they are not specifically used to determine dosages for thyroid replacement therapy. The dosage of thyroid replacement therapy is usually determined by a healthcare provider based on the patient’s medical condition, weight, age, laboratory test results, and response to treatment.
Choice C rationale
The neonatal screening test is not specifically used for the early detection of intellectual disabilities. However, it is important to note that untreated congenital hypothyroidism can lead to intellectual disabilities. Therefore, early detection and treatment of hypothyroidism generally result in normal growth and development.
Choice D rationale
While these laboratory values can provide data about the thyroid function of the newborn, they do not directly provide data to anticipate delays in growth and development. However, untreated congenital hypothyroidism can lead to growth and developmental delays. Therefore, early detection and treatment of hypothyroidism generally result in normal growth and development.
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