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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["6.8"]

Explanation

Converting the weight to kg:
Client weight = 198 lbs 1 lb = 0.453592 kg

Client weight in kg = 198 lbs 0.453592 kg/lb = 90.7 kg
Calculating the desired dopamine infusion rate:
Dose = 2 mcg/kg/minute Client weight = 90.7 kg
Desired infusion rate = Dose Client weight = 2 mcg/kg/minute 90.7 kg = 181.4 mcg/minute

Determining the dopamine concentration in the bag:

Dopamine amount = 400 mg Bag volume = 250 mL
Dopamine concentration = Dopamine amount / Bag volume = 400 mg / 250 mL = 1.6 mg/mL
Convert mg/mL to mcg/mL: 1.6 mg/mL 1000 mcg/mg = 1600 mcg/mL

Calculating the rate in mL/minute:

Desired infusion rate = 181.4 mcg/minute Dopamine concentration = 1600 mcg/mL
Rate (mL/minute) = Desired infusion rate (mcg/minute) / Dopamine concentration (mcg/mL)
Rate = 181.4 mcg/minute / 1600 mcg/mL = 0.1134 mL/minute

Converting the rate to mL/hour:
Rate (mL/minute) = 0.1134 mL/minute Conversion factor: 60 minutes/hour
Rate (mL/hour) = 0.1134 mL/minute 60 minutes/hour = 6.8 mL/hour (round to nearest tenth)

Therefore, the nurse should set the IV pump to deliver approximately 6.8 mL/hour.

A. Wearing gloves when interviewing the client. B. Allowing the client to ventilate feelings. C. Encouraging the client to join a support group. D. Shaking the client's hand during an introduction.

Correct Answer is D

Explanation

A. Wearing gloves when interviewing the client. This behavior may make the client feel stigmatized or rejected, as it could imply that the nurse perceives them as contagious or untouchable.
B. Allowing the client to ventilate feelings. While this is important for emotional support, it does not directly address the psychosocial need for acceptance.
C. Encouraging the client to join a support group. This can help the client feel less isolated and gain support from others with similar experiences, but it is not as immediate or direct as personal interaction.
D. Shaking the client's hand during an introduction. This gesture of physical contact can significantly convey acceptance and normalcy, helping the client feel respected and accepted despite their condition.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

Correct Answer is ["6.8"]

Explanation

The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this client's psychosocial need for acceptance?

Correct Answer is D

Explanation

A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?

The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity?

Exhibits Following the fluid bolus, the client is more awake and able to answer questions. What questions are appropriate for the secondary survey? Select all that apply.

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having sex with multiple partners. Which response should the nurse provide?

A client with a right hemopneumothorax has a chest tube connected to suction. While turning to the left side, the client becomes suddenly short of breath and anxious. Which intervention should the nurse implement?

Exhibits here Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification?