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 ["C","D","G"]

Explanation

A. The client may be developing sepsis.

Sepsis typically presents with symptoms such as fever, increased heart rate, increased respiratory rate, and altered blood pressure. There is no indication of these signs in the provided data,
making sepsis an unlikely cause for the change in the Glasgow Coma Scale (GCS) score.

B. The client may be dehydrated.

Dehydration can affect cognitive function, but there is no evidence suggesting dehydration in this scenario (e.g., normal heart rate, blood pressure, and no noted intake/output imbalance).
C. The client may have increasing symptoms of head injury.

A decrease in GCS score can indicate worsening head injury symptoms, such as increased intracranial pressure or bleeding.
D. The client may have been sleeping.

Sleeping can temporarily affect the GCS score, particularly the eye-opening component.

E. The client may be improving clinically.

Improvement clinically would likely result in a stable or improved GCS score, not a decrease.

F. The client may require more morphine.

Needing more morphine would typically be due to increased pain, but this should not directly affect the GCS score unless severe pain is causing altered consciousness, which is not indicated here.
G. The client may be experiencing sedative effects of morphine.

Morphine, especially given intravenously, can cause sedation, which could lower the GCS score.

H. The client may need food.

Needing food would not typically cause an immediate change in GCS score unless associated with severe hypoglycemia, which is not indicated by the provided data.

A. Gained 10 lb (4.5 kg) within one month. B. Drinks more fluids than previously. C. Voids only one or two times per day. D. Refuses to eat favorite meals at home.

Correct Answer is B

Explanation

A. Gained 10 lb (4.5 kg) within one month. Weight gain is not typically associated with the onset of type 1 diabetes. In fact, weight loss is more common due to the body's inability to use glucose properly.
B. Drinks more fluids than previously. Increased thirst (polydipsia) is a classic symptom of type 1 diabetes due to high blood sugar levels causing dehydration.
C. Voids only one or two times per day. Increased urination (polyuria) is a common symptom of type 1 diabetes as the body attempts to excrete excess glucose, so decreased urination is unlikely.
D. Refuses to eat favorite meals at home. While changes in appetite can occur, it is not a primary symptom of type 1 diabetes. Increased hunger (polyphagia) is more typical.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["C","D","G"]

Explanation

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Correct Answer is B

Explanation

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