A client returns from lumbar spinal surgery with a dressing that has clear fluid leaking. Which action should the nurse implement immediately?

• A. Test the fluid on the dressing for glucose
• B. Replace the dressing and monitor for drainage
• C. Send a sample for culture before testing
• D. Apply a tourniquet to the wound site

Answer: (A)

A clear fluid draining from the wound after lumbar spine surgery strongly suggests a cerebrospinal fluid (CSF) leak, and identifying it quickly is crucial because a CSF leak can lead to meningitis and wound healing problems. The fastest way to confirm whether the fluid is CSF at the bedside is to test it for glucose, since CSF contains glucose while most other wound drainage fluids do not. A positive glucose result supports a CSF leak, so the nurse should notify the physician promptly and implement the appropriate CSF-leak precautions and plan of care. Replacing the dressing and monitoring for drainage is important, but it doesn’t confirm the leak; sending a sample for culture can be helpful but should come after confirming CSF leakage. An applied tourniquet is inappropriate and could cause harm.