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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason:Placing the client in a sitting position helps to lower blood pressure by promoting venous return and is the first action to take in cases of autonomic dysreflexia²³.

Choice B reason:While examining for skin breakdown is important, it is not the first action to take when autonomic dysreflexia is suspected.

Choice C reason:Checking the bladder for distention is a critical step, but it should be done after positioning the client to address immediate blood pressure concerns.

Choice D reason:Checking for fecal impaction is also important but follows the initial step of positioning the client to manage blood pressure.

A. Shake the bag to mix the fat. B. Administer the bag of solution. C. Return the bag to the pharmacy. D. Turn the bag upside down one time.

Correct Answer is C

Explanation

Choice A reason:Shaking the bag is not recommended as it may not adequately mix the solution and could cause emulsion instability.

Choice B reason:Administering the bag as is could be harmful due to the risk of fat embolism or other complications from an unstable emulsion.

Choice C reason:Returning the bag to the pharmacy is the appropriate action to ensure the client receives a properly mixed and safe emulsion.

Choice D reason:Turning the bag upside down one time is not sufficient to mix the emulsion and does not address the potential instability of the solution.

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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?

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