The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

Test the fluid on the dressing for glucose.

Mark the drainage area with a pen and continue to monitor.

Change the dressing using a compression bandage.

Document the findings in the electronic medical record.

Answer and Explanation

The Correct Answer is A

A. Test the fluid on the dressing for glucose.
This is the correct action. Clear fluid on a dressing after lumbar spinal surgery could indicate a cerebrospinal fluid (CSF) leak. Testing the fluid for glucose is essential because CSF contains glucose, whereas normal wound drainage does not. A positive glucose test would confirm the presence of CSF, indicating a potential complication that requires immediate medical attention.

B. Mark the drainage area with a pen and continue to monitor.
While monitoring the size of the drainage area can be useful, it is not the immediate priority. The nurse should first determine whether the clear fluid is CSF.

C. Change the dressing using a compression bandage.
Changing the dressing might be necessary, but using a compression bandage without first identifying the nature of the fluid could be inappropriate and potentially harmful if the fluid is CSF.

D. Document the findings in the electronic medical record.
Documentation is important, but it is not the immediate action. The nurse needs to identify the nature of the fluid first.

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Correct Answer is A

Explanation

A. Keep diabetic medication on schedule as prescribed.

This is the correct answer because maintaining a regular schedule for diabetic medication is crucial for managing blood glucose levels and preventing complications.

B. Limit maximum daily fat intake to 15% of total calories.

While reducing fat intake can be beneficial for overall health, it is not directly related to managing acute blood glucose levels or preventing immediate complications of diabetes.

C. Check blood sugar levels every four to six hours every day.

Frequent monitoring of blood sugar levels is important, but checking every four to six hours may not be necessary for all clients, especially if they are not on insulin or if their diabetes is well-controlled. It depends on individual needs and physician recommendations.

D. Restrict alcoholic beverages to no more than 1-2 per week.

Limiting alcohol intake is good advice for overall health and diabetes management, but it is not the most critical action compared to keeping medications on schedule to prevent complications.

A. Ensure that the infant's crib mattress is firm. B. Prop the infant with a pillow when in a side-lying position. C. Place the infant in a prone position whenever possible. D. Swaddle the infant in a blanket for sleeping.

Correct Answer is A

Explanation

A. Ensure that the infant's crib mattress is firm. A firm mattress reduces the risk of SIDS by preventing the infant from sinking into a soft surface, which can obstruct breathing.

B. Prop the infant with a pillow when in a side-lying position. Propping with a pillow is not recommended as it can increase the risk of suffocation and is not a recommended SIDS prevention measure.
C. Place the infant in a prone position whenever possible. Placing an infant in a prone (stomach) position is a significant risk factor for SIDS. Infants should be placed on their backs to sleep.
D. Swaddle the infant in a blanket for sleeping. While swaddling can be safe if done correctly, it is not as critical as ensuring a firm mattress. Additionally, improper swaddling can pose risks if the blanket becomes loose.

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The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

Nursing Test Bank

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