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 ["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.

A. Fractured femur B. Severe anorexia nervosa C. Gastrointestinal obstruction D. Chronic diarrhea and vomiting

Correct Answer is C

Explanation

Choice A reason: A fractured femur, while a serious injury, does not inherently contraindicate the use of lipid emulsions. These patients may require additional nutrition if they are unable to eat adequately by mouth, and lipid emulsions can be part of their parenteral nutrition regimen if needed.

Choice B reason: Severe anorexia nervosa is a condition that can lead to malnutrition and may necessitate the use of parenteral nutrition, including lipid emulsions, to provide essential nutrients. However, care must be taken to avoid refeeding syndrome, a potentially fatal condition that can occur when malnourished patients begin to refeed too quickly.

Choice C reason: Gastrointestinal obstruction is a condition that could be exacerbated by the administration of lipid emulsions. In cases of obstruction, enteral or parenteral nutrition may need to be carefully managed or avoided until the obstruction is resolved to prevent further complications. While lipid emulsions are a valuable component of parenteral nutrition, their use must be carefully considered in the context of the patient’s overall clinical condition. In the case of gastrointestinal obstruction, the nurse would be most concerned about the prescription of a lipid emulsion due to the potential for exacerbating the obstruction and complicating the patient’s condition.

Choice D reason: Chronic diarrhea and vomiting can lead to dehydration and electrolyte imbalances, but they do not directly contraindicate the use of lipid emulsions. However, the underlying cause of these symptoms should be addressed, and fluid and electrolyte balance should be carefully monitored.

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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

Correct Answer is ["125"]

Explanation

The nurse would be most concerned about a prescription for a lipid emulsion for a client with which condition?

Correct Answer is C

Explanation

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