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","B","C","D","E","F"]

Explanation

Choice A reason:Profuse vomiting with a fecal odor can occur in large bowel obstructions due to the backward flow of bowel contents.

Choice B reason:Epigastric abdominal distention is a common finding in bowel obstructions due to the accumulation of gas and fluids.

Choice C reason:Intermittent abdominal cramping results from the bowel's attempt to push contents through the obstructed area.

Choice D reason:Ribbon-like stools or diarrhea may occur if there is a partial obstruction allowing some contents to pass.

Choice E reason:Metabolic acidosis can develop due to the accumulation of lactic acid from tissue hypoxia and decreased perfusion.

Choice F reason:Severe fluid and electrolyte imbalance can result from vomiting and the inability to absorb fluids and nutrients properly.

Correct Answer is ["60"]

Explanation

- Step 1: Identify the required dose in grams. The client is scheduled to receive 30 grams of lactulose.

- Step 2: Identify the concentration of the available solution. The available solution contains 5 grams of lactulose per 10 mL.

- Step 3: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:

- 5 grams is to 10 mL as 30 grams is to X mL.

- In other words, 5 g : 10 mL = 30 g : X mL.

- Step 4: Solve for X using cross-multiplication and division:

- Cross-multiplication gives us: 5 g × X mL = 30 g × 10 mL.

- Simplifying this gives us: 5X = 300.

- Dividing both sides by 5 gives us: X = 300 ÷ 5.

- Calculating the division gives us: X = 60.

60 mL of the lactulose solution should be poured into the medication cup to administer the required dose of 30 grams.

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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

A client presents with a possible bowel obstruction, and the nurse completes a detailed abdominal assessment. Which of the following clinical manifestations are consistent with a large bowel obstruction? (Select all that apply).

Correct Answer is ["A","B","C","D","E","F"]

Explanation

The client is scheduled to receive 30 grams of lactulose orally every 12 hours. An oral solution containing 5 g/10 mL is available. How many mL should be poured into the medication cup to administer the required dose?

Correct Answer is ["60"]

Explanation

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