The nurse notices the presence of clear fluid on the surgical dressing of a patient who has just returned to the unit following lumbar spinal surgery.
What immediate action should the nurse take?
Test the fluid on the dressing for glucose.
Replace the dressing using a compression bandage.
Mark the drainage area with a pen and continue monitoring.
Document the findings in the electronic medical record.
The Correct Answer is A
Choice A rationale
Testing the fluid on the dressing for glucose is the immediate action the nurse should take. Clear fluid could be cerebrospinal fluid (CSF), which is often released following spinal surgery. CSF contains glucose, so a positive glucose test would confirm it is CSF.
Choice B rationale
Replacing the dressing using a compression bandage is not the immediate action the nurse should take. While it is important to manage the drainage and prevent infection, the nurse first needs to identify what the clear fluid is.
Choice C rationale
Marking the drainage area with a pen and continuing to monitor is not the immediate action the nurse should take. While this can be part of ongoing wound care and monitoring, the nurse first needs to identify what the clear fluid is.
Choice D rationale
Documenting the findings in the electronic medical record is an important step, but it should not be the immediate action. The nurse first needs to identify what the clear fluid is, as it could indicate a complication from the surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While seizure precautions are important for clients receiving certain medications or with certain conditions, they are not typically necessary for clients receiving dopamine. Dopamine, an adrenergic agonist, does not typically increase the risk of seizures.
Choice B rationale
Assessing pupillary response to light hourly is not typically necessary for clients receiving dopamine. Dopamine does not typically affect pupillary response.
Choice C rationale
Measuring urinary output every hour is an important intervention for a client receiving dopamine. Dopamine at low to moderate doses can dilate renal blood vessels, which can increase urine output. Therefore, monitoring urinary output can help assess the effectiveness of the medication and the client’s renal perfusion.
Choice D rationale
While it is important to monitor electrolyte levels in clients receiving certain medications, frequent monitoring of serum potassium is not typically necessary for clients receiving dopamine. Dopamine does not typically affect serum potassium levels.
Correct Answer is C
Explanation
Choice A rationale
Vegetarian lasagna with cheese and spinach, a tossed green salad with ranch dressing, and fresh fruit is a balanced meal. However, it may not be the best choice for a patient with type 2 diabetes due to the high carbohydrate content in the lasagna and the dressing.
Choice B rationale
Fried chicken breast, mashed potatoes, green beans, sliced tomatoes, and fresh apple pie is not the best choice for a patient with type 2 diabetes. Fried foods and mashed potatoes are high in carbohydrates and fats, which can raise blood sugar levels.
Choice C rationale
Grilled fish with whole-grain brown rice, steamed broccoli, and a pear poached in red wine is a good choice for a patient with type 2 diabetes. This meal is balanced with lean protein, whole grains, and vegetables, which can help control blood sugar levels.
Choice D rationale
Lean hamburger with cheese, tomato, and lettuce on a whole-wheat bun, and angel food cake is not the best choice for a patient with type 2 diabetes. Although the hamburger is lean, the whole-wheat bun and angel food cake are high in carbohydrates, which can raise blood sugar levels.
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