A nurse notices clear fluid on the surgical dressing of a patient who has just returned from lumbar spinal surgery. What should be the nurse’s immediate course of action?

Choice A rationale Testing the fluid on the dressing for glucose is the immediate course of action when a nurse notices clear fluid on the surgical dressing of a patient who has just returned from lumbar spinal surgery. Clear fluid could be cerebrospinal fluid (CSF), which contains glucose. If the fluid is positive for glucose, it could indicate a CSF leak, which requires immediate medical attention. Choice B rationale Changing the dressing using a compression bandage is not the immediate course of action. The source of the fluid needs to be identified first. Choice C rationale Marking the drainage area with a pen and continuing to monitor is not the immediate course of action. The source of the fluid needs to be identified first. Choice D rationale Documenting the findings in the electronic medical record is important, but it is not the immediate course of action. The source of the fluid needs to be identified first.