A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?

Oral temperature of 37.2° C (99° F)

Clear drainage on the dressings

Drain output 75 mL in 4 hr

Decreased bowel sounds in all quadrants of the abdomen

Answer and Explanation

The Correct Answer is B

Rationale:
A. Oral temperature of 37.2° C (99° F): This is a normal postoperative temperature and does not indicate infection or any other complication. Mild elevations in temperature are expected after surgery.

B. Clear drainage on the dressings: Clear drainage, particularly if it is watery and not tinged with blood, may indicate cerebrospinal fluid (CSF) leakage. This is a serious complication of spinal surgery and requires immediate evaluation to prevent infection and further neurological issues.

C. Drain output 75 mL in 4 hr: This amount of drainage is within normal limits for the early postoperative period, depending on the surgeon's parameters. It is not inherently concerning unless it becomes excessive or has abnormal characteristics.

D. Decreased bowel sounds in all quadrants of the abdomen: Decreased bowel activity is common after surgery due to anesthesia and immobility. It is expected in the immediate postoperative period and not necessarily a sign of a complication unless prolonged.

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Correct Answer is C

Explanation

Rationale:

A. WBC count: Monitoring the white blood cell count is useful for detecting infection, but heroin toxicity primarily affects the respiratory system. An elevated or normal WBC does not provide immediate information about the client's ventilation or gas exchange status.

B. Intake and output: Tracking fluid balance is important for overall patient monitoring, especially in critically ill clients. However, it does not provide direct insight into the effectiveness of mechanical ventilation or the client's oxygenation status.

C. ABGs: Arterial blood gases are the priority assessment because they directly measure the client's oxygenation, ventilation (CO₂ removal), and acid-base status. Since heroin toxicity can cause respiratory depression, ABGs are essential to evaluate the effectiveness of mechanical ventilation.

D. Blood glucose level: Although monitoring glucose is important in critically ill clients, heroin use is not typically associated with hypo- or hyperglycemia. Blood glucose assessment is not as urgent as evaluating respiratory function in this scenario.

A. Asthma B. Diabetes mellitus C. Pernicious anemia D. Osteoporosis

Correct Answer is B

Explanation

A. Asthma: Asthma affects the respiratory system and does not have a direct link to urinary tract infections. It does not alter urinary tract anatomy or immune defenses specific to the urinary system.

B. Diabetes mellitus: Clients with diabetes are at increased risk for UTIs due to immune suppression, glucosuria that promotes bacterial growth, and possible bladder dysfunction (e.g., urinary retention) from diabetic neuropathy. Poor glycemic control further raises infection susceptibility.

C. Pernicious anemia: This condition is related to vitamin B12 deficiency and affects red blood cell production and neurological function, but it does not specifically predispose clients to UTIs.

D. Osteoporosis: Osteoporosis involves reduced bone density and is not associated with urinary tract infections. It does not impact the urinary or immune systems directly.

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A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurse's priority?

Correct Answer is C

Explanation

A nurse is reviewing the health histories of a group of clients. Which of the following findings should the nurse identify as an indication that a client is at an increased risk for urinary tract infections (UTIs)?

Correct Answer is B

Explanation

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