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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Cardiovascular
- Capillary refill 4 seconds
- A prolonged capillary refill time indicates poor peripheral perfusion, which can be a sign of hypoxia. Hypoxia can lead to reduced oxygen delivery to the tissues, resulting in delayed capillary refill.
Respiratory
- Oxygen saturation 90% on room air
- An oxygen saturation level of 90% is below the normal range (95-100%) and indicates that the blood is not adequately oxygenated, which is a direct sign of hypoxia.
- Respiratory rate 28 breaths/minute
- An elevated respiratory rate (tachypnea) is a common compensatory mechanism in response to hypoxia. The body attempts to increase oxygen intake and carbon dioxide expulsion by breathing more rapidly.
Neurological
- Anxious
- Anxiety can be a symptom of hypoxia. When the brain and other vital organs do not receive enough oxygen, it can trigger a sense of anxiety and restlessness as part of the body's alarm system.
- Restless
- Restlessness is another common symptom of hypoxia. It occurs because the body is trying to compensate for the lack of oxygen, leading to increased agitation and an inability to remain
calm.
Rationales for the Incorrect Choices:
- Cardiovascular
- Heart rate 101 beats/minute: While an elevated heart rate can be a compensatory response to hypoxia, it alone does not directly indicate hypoxia.
- Blood pressure 145/89 mm Hg: Elevated blood pressure is not a direct indicator of hypoxia and can be influenced by various factors including anxiety and pain.
- Respiratory
- Productive cough: A productive cough suggests respiratory infection or inflammation but does not directly measure oxygenation status or indicate hypoxia.
- Neurological
- Awake and alert: Being awake and alert indicates normal mental status and does not suggest hypoxia. Hypoxia typically affects cognitive function, leading to confusion or decreased level of consciousness in more severe cases.
Correct Answer is A
Explanation
A. Do not take any over-the-counter medications. This is crucial because many over-the-counter medications, including those containing acetaminophen, can further damage the liver. Avoiding these medications is essential to prevent further hepatic injury.
B. Eat a high carbohydrate, low fat, low protein diet. While diet can influence liver health, this specific dietary advice is less critical than preventing further liver damage from medications.
C. Call the crisis hot line if feeling lonely. This is important for mental health support, but the immediate physical health concern related to liver damage takes precedence.
D. Avoid exposure to large crowds. This may be relevant if the client is immunocompromised due to liver damage, but it is not as directly related to preventing further liver injury as avoiding certain medications.
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