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?

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.

Rationale:
A. Place monitoring cords and tubes in a stockinette: Clients with latex allergies are at risk for serious reactions from contact with latex-containing equipment. Covering cords and tubing with a stockinette helps prevent direct skin exposure to latex, reducing the risk of an allergic reaction.

B. Schedule the client for the last surgery of the day: Clients with latex allergies should be scheduled as the first surgery of the day to minimize their exposure to airborne latex particles and reduce contamination from previously used equipment or surfaces.

C. Choose rubber injection ports for fluid administration: Rubber injection ports often contain latex, which can trigger severe allergic reactions. For clients with latex allergies, non-latex or latex-free alternatives must be used for all fluid and medication administration.

D. Have phenytoin IV readily available: Phenytoin is an anticonvulsant used to manage seizures and is not specifically indicated for treating allergic reactions. Epinephrine, antihistamines, and corticosteroids should be available in case of an anaphylactic reaction.