The nurse is caring for a client on the operative day following a herniated lumbar disk. What would be a priority nursing assessment?
1. Monitor the level and location of pain.
2. Determine peripheral pulse rate.
3. Evaluate the client for presence of venous stasis.
4. Check the dressing for presence of clear fluid.
Answer: 4
In a lumbar laminectomy, observing the dressing for presence of clear drainage, which may be spinal fluid, is critical. This must be reported to the surgeon immediately, and the client will be at an increased risk of infection. The pain level and location should be closely monitored, but the observation of the dressing for spinal fluid is more critical. The client will need to be evaluated for presence of and prevention of venous stasis, but spinal fluid leakage is more important the operative day. Presence and quality of peripheral pulses, not rate, should be assessed as part of the total assessment.
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