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. The client's bed has a three-prong plug attached to the electrical cord: A three-prong plug provides grounding and is a standard safety feature. It helps prevent electric shock and is not considered a hazard.

B. A protective cover is inserted into an unused outlet: Outlet covers are recommended, especially in homes with children, to prevent accidental electrical shock. This is a safety measure, not a hazard.

C. An IV pump is plugged into an outlet near a sink: This is a safety hazard because electrical devices should not be used near water sources. The proximity to the sink increases the risk of electrical shock or short-circuiting if moisture contacts the outlet or device.

D. An electrical cord is coiled and secured to the floor: Coiling and securing cords can prevent tripping hazards and is generally acceptable as long as the cord is not damaged or covered in a way that could lead to overheating.

A. BUN 16 mg/dL (10 to 20 mg/dL) B. Urine output 40 mL every hour for 3 hr C. Hct 42% (37% to 47%) D. Surgical drain output 300 mL during an 8-hr shift

Correct Answer is D

Explanation

Rationale:
A. BUN 16 mg/dL (10 to 20 mg/dL): This is a normal blood urea nitrogen level and does not indicate dehydration or fluid volume deficit. Elevated BUN may suggest volume depletion, but this value is within the expected range.

B. Urine output 40 mL every hour for 3 hr: A urine output of 30 mL/hr or greater is considered adequate in most adult clients. Therefore, 40 mL/hr is within acceptable limits and does not suggest fluid volume deficit.

C. Hct 42% (37% to 47%): This hematocrit level falls within the normal range and does not indicate hemoconcentration. Elevated hematocrit could signal dehydration, but this value alone does not support that conclusion.

D. Surgical drain output 300 mL during an 8-hr shift: This is a significant amount of fluid loss postoperatively and can contribute to fluid volume deficit. High drain output following surgery, especially spinal procedures, increases the client's risk for hypovolemia and should be closely monitored.

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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

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