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 ["167"]

Explanation

- Step 1: Identify the client's weight in pounds. The client weighs 245 lbs.

- Step 2: Convert the client's weight from pounds to kilograms. We know that 1 kg = 2.2 lbs. So, 245 lbs = 245 ÷ 2.2 kg. Calculating the division gives us approximately 111.36 kg.

- Step 3: Identify the prescribed dose in mg/kg. The client is scheduled to receive 1.5 mg/kg of enoxaparin.

- Step 4: Calculate the total dose in mg. We can do this by multiplying the client's weight in kg by the prescribed dose in mg/kg:

- Total dose = 1.5 mg/kg × 111.36 kg.

- Calculating the multiplication gives us approximately 167.04 mg.

- Step 5: Round the total dose to the nearest whole number. Rounding 167.04 gives us 167.

administer 167 mg of enoxaparin per dose.

A. The client states that pain occurs 30 minutes to 60 minutes after a meal. B. The client states that pain often occurs at night. C. The client reports a sensation of bloating. D. The client reports pain relieved by eating. E. The client experiences pain upon palpation of the epigastric region.

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

Explanation

Choice A reason: Pain occurring 30 to 60 minutes after a meal is a common symptom of gastric ulcers due to the increased gastric acid secretion during digestion that can aggravate the ulcer.

Choice B reason: Pain at night is also typical for gastric ulcers as the circadian rhythm can influence acid secretion, potentially leading to increased discomfort during the night.

Choice C reason: A sensation of bloating can be associated with gastric ulcers due to delayed gastric emptying or increased sensitivity of the stomach lining.

Choice D reason:Pain relieved by eating is indicative of gastric ulcers because food can act as a buffer to stomach acid, temporarily relieving pain².

Choice E reason:Pain upon palpation of the epigastric region is expected in clients with gastric ulcers due to the localized inflammation and sensitivity of the stomach lining².

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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 ["167"]

Explanation

A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following findings should the nurse expect? (Select all that apply).

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

Explanation

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