A patient is two days after spinal surgery. The nurse notices clear, watery drainage from the wound and the patient reports a severe headache that worsens when sitting upright. Which action should the nurse take first?

Correct answer: A. Place the patient flat and notify the surgeon

  • A. Place the patient flat and notify the surgeon
  • B. Encourage walking to improve spinal circulation
  • C. Apply a warm dressing and reassess in one hour
  • D. Raise the head of the bed and increase oral fluids

Explanation

Clear drainage with a postural headache may indicate cerebrospinal fluid leakage. The patient should be kept flat and the finding reported promptly; ambulation and head elevation can increase the leak or symptoms.

Submitted by a TestUstad contributor and published by the TestUstad editorial teamLast updated
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About Orthopaedic Nursing

Covers fractures, dislocations, arthritis, osteoporosis, joint replacement, spinal disorders and complications of immobility. It includes neurovascular assessment, traction and cast care, mobility assistance, pain control, prevention of pressure injuries and deep vein thrombosis, and the difference between compartment syndrome and ordinary postoperative swelling.

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