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:Increased serum amylase is a common finding in acute pancreatitis as it is released from the inflamed pancreas[^10^].

Choice B reason:A decreased WBC count is not typically associated with acute pancreatitis; an increased count may indicate infection or inflammation.

Choice C reason:Serum calcium is often decreased in acute pancreatitis due to fat saponification and hypoalbuminemia.

Choice D reason:Decreased serum lipase would not be expected; increased levels are indicative of acute pancreatitis, similar to amylase[^10^].

A. Severe fluid and electrolyte imbalance B. Upper abdominal distention C. Metabolic acidosis D. Projectile vomiting with a fecal odor E. Diarrhea or ribbon-like stools

Correct Answer is ["A","B","D"]

No explanation

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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