In assessing the client 8 hours after a lumbar laminectomy, the nurse observes the dressing to be wet with clear fluid. What is the nurse's best action?
A. Assess the client's level of consciousness.
B. Place the client in a semi-Fowler's position.
C. Document the finding as the only action.
D. Notify the physician after reinforcing the surgical dressing aseptically.
D
The finding of clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency.
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The primipara at 39 weeks' gestation states to the nurse, "I can breathe easier now." What is the nurse's best response?
a. "You labor will start any day now since the baby has dropped." b. "That process is called lightening. Do you have to urinate more frequently?" c. "Contact your health care provider when your contractions are every 5 minutes for 1 hour." d. "You will likely not feel you baby's movements as much now, so do not be concerned."
Which should the nurse implement to administer a liquid medication?
1. Place medicine cup on the counter; stand over cup to pour. 2. Use a syringe to transfer the medication into the medicine cup. 3. Pour with the label on the bottle facing away from nurse's hand. 4. Match medication level at meniscus to a specified amount on cup.
The nurse is preparing to provide morning care to a client. What should the nurse explain to the client as the reason for a daily bath?
1. Assess skin integrity 2. Develop a nurse–client relationship 3. Moisturize the skin 4. Stimulate circulation
A nurse is taking care of a client who has sustained head trauma as a result of a motor vehicle accident. The nurse notices fluid leaking from the nose and ears
Based on this information, what diagnostic test should this fluid be tested for immediately? A) Sodium B) Calcium C) Glucose D) Potassium