A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?
Test the drainage for the halo sign.
Ask the client to blow his nose.
Notify the physician.
Suction the nostril.
The Correct Answer is A
Choice A reason:Testing the drainage for the halo sign is the first action the nurse should take, as clear drainage from the nose following a basal skull fracture could indicate a cerebrospinal fluid (CSF) leak, which contains glucose.
Choice B reason:Asking the client to blow his nose could potentially increase the risk of infection or worsen a CSF leak and is not recommended as a first action.
Choice C reason:While notifying the physician is important, it should be done after confirming whether the drainage is CSF, which would require immediate medical intervention.
Choice D reason:Suctioning the nostril is not the first action to take, as it could potentially disrupt the site of the leak and is not diagnostic of a CSF leak.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
- Step 1: Identify the required dose in micrograms (mcg). The client is scheduled to receive 125 mcg of digoxin.
- Step 2: Identify the concentration of the available tablet. The available tablet contains 0.25 mg of digoxin.
- Step 3: Convert the tablet concentration from mg to mcg. We know that 1 mg = 1000 mcg. So, 0.25 mg = 0.25 × 1000 mcg = 250 mcg.
- Step 4: Calculate the number of tablets needed to deliver the required dose. We can set up a proportion to solve for this:
- 250 mcg is to 1 tablet as 125 mcg is to X tablets.
- In other words, 250 mcg : 1 tablet = 125 mcg : X tablets.
- Step 5: Solve for X using cross-multiplication and division:
- Cross-multiplication gives us: 250 mcg × X tablets = 125 mcg × 1 tablet.
- Simplifying this gives us: 250X = 125.
- Dividing both sides by 250 gives us: X = 125 ÷ 250.
- Calculating the division gives us: X = 0.5.
So, the nurse should administer 0.5 tablets per dose to deliver the required dose of 125 mcg.
Correct Answer is A
Explanation
Choice A: Troponin Troponin levels increase within 3-12 hours from the onset of chest pain, peak at 24-48 hours, and return to baseline over 5-14 days. Troponin is a protein found in cardiac muscle fibers that regulates muscular contraction. When heart muscle is damaged, as in the case of an MI, troponin is released into the bloodstream. The elevation of troponin levels is a key indicator of myocardial infarction and can be used to diagnose and assess the extent of heart muscle damage. Troponin is the most reliable laboratory value that is expected to be elevated following a myocardial infarction, making it the correct choice in this scenario.
Choice B: Aspartate aminotransferase (AST) AST is an enzyme found in high concentrations in the liver, heart, muscles, kidneys, and brain. It is released into the bloodstream when any of these tissues are damaged. While AST can be elevated in cases of MI, it is not as specific as troponin because it is present in many other tissues besides the heart.
Choice C: Serum amylase Serum amylase is an enzyme that helps digest carbohydrates and is primarily associated with the pancreas and salivary glands. Its elevation is not specifically related to myocardial infarction but can be seen in other conditions such as pancreatitis.
Choice D: Unconjugated bilirubin Unconjugated bilirubin is a breakdown product of hemoglobin from red blood cells. Elevated levels of unconjugated bilirubin are typically associated with conditions affecting the liver or the breakdown of red blood cells, not myocardial infarction.
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