ATI NCLEX Medical Surgical Assessment 1

A nurse in a postanesthesia care unit is performing a postoperative assessment on a client who is recovering from a lumbar laminectomy and has a surgical drain. Which of the following findings should the nurse identify as a complication of the procedure A. Clear drainage on the surgical dressing B. Pain level of 5 on a scale from 0 to 10 C. Reports discomfort when log rolling D. Drainage output 30m: during the first hour - A Clear fluid on or around the surgical dressing following a laminectomy is an indication of CSF leak. Place the client flat to prevent a spinal headache and notify provider immediately A nurse in an emergency department is monitoring a client who reports angina. Which of the following findings should indicate to the nurse that the client might have experienced a myocardial infarction (MI) A. Increased troponin B. Decreased creatinine kinase MB C. Cholesterol 300 mg/dL D. C- reactive protein 1.2 mg/dL - A Troponin is a myocardial muscle protein released into the blood stream as a result of injury to the heart muscle. Troponin levels increase within 2-3 hr following an MI -- B, creatinine kinase MB elevates when there is injury to brain tissue, myocardial muscle, or skeletal muscle C, elevated cholesterol increases the risk for cardiovas