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","E","G"]

Explanation

A. Involve your mother in the decision-making process.

Involving the client in decision-making can help maintain her autonomy, reduce feelings of

helplessness, and potentially decrease the daughter's caregiver burden by sharing responsibility.

B. Moving your mother into a care facility will show her that you do not love her.

This statement is incorrect and could exacerbate feelings of guilt and stress in the caregiver. Decisions about care facilities should be based on the best interests of both the client and the caregiver, not on guilt or misconceptions about love.
C. It is okay not to love or like your mother when you are caring for her.

This statement might be misunderstood and could increase feelings of guilt and stress. It's more helpful to acknowledge that caregiving can be challenging and that it's normal to have mixed emotions.
D. You made a promise to your mother that you need to keep.

This statement could increase stress by suggesting that the caregiver has no options or flexibility, potentially exacerbating feelings of obligation and guilt.
E. Take time for yourself and the other relationships that you care about.

Taking time for self-care and maintaining other relationships is crucial for reducing caregiver stress and preventing burnout.
F. Saying "no" to things involving the care of your mother is a selfish action.

This statement is incorrect and could increase feelings of guilt and stress. It's important for caregivers to set boundaries and understand that it's okay to say "no" sometimes to maintain their well-being.
G. Helping your mother should be easier than raising a child.

This statement is misleading. Caregiving for an elderly parent can be as demanding, if not more so, than raising a child. It's important to recognize and validate the challenges of caregiving to provide appropriate support.
H. Avoid discussion of negative situations that may occur in the future.

This statement is not advisable. Open and honest communication about potential challenges is important for planning and reducing stress through preparedness.

A. Measure urinary output every hour. B. Initiate seizure precautions. C. Assess pupillary response to light hourly. D. Monitor serum potassium frequently.

Correct Answer is A

Explanation

A. Measure urinary output every hour. Dopamine is commonly used to improve blood pressure and renal perfusion in hypotensive clients. Monitoring urinary output is crucial because dopamine can increase renal blood flow and urine output. Hourly measurement allows for early detection of changes in renal function and urine output, enabling prompt intervention if needed.
B. Initiate seizure precautions. Seizures are not a common adverse effect of dopamine administration. Therefore, initiating seizure precautions is unnecessary in this context.
C. Assess pupillary response to light hourly. While assessing pupillary response is important in neurological assessments, it is not a priority intervention specifically related to dopamine
administration for hypotension.

D. Monitor serum potassium frequently. Dopamine administration is not directly associated with alterations in serum potassium levels. While electrolyte monitoring is important in some
situations, it is not the primary concern when administering dopamine for hypotension. Monitoring urinary output is more pertinent in this scenario.

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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

Correct Answer is ["A","E","G"]

Explanation

A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Correct Answer is A

Explanation

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