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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["24"]
Explanation
- Step 1: Identify the prescribed dose in units per hour. The client is scheduled to receive 1,200 units/hr of heparin.
- Step 2: Identify the concentration of the available solution. The available solution contains 25,000 units of heparin in 500 mL D5W.
- Step 3: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:
- 25,000 units is to 500 mL as 1,200 units is to X mL.
- In other words, 25,000 units : 500 mL = 1,200 units : X mL.
- Step 4: Solve for X using cross-multiplication and division:
- Cross-multiplication gives us: 25,000 units × X mL = 1,200 units × 500 mL.
- Simplifying this gives us: 25,000X = 600,000.
- Dividing both sides by 25,000 gives us: X = 600,000 ÷ 25,000.
- Calculating the division gives us: X = 24.
Set the IV pump to deliver 24 mL/hr to administer the required dose of 1,200 units/hr.
Correct Answer is A
Explanation
Choice A reason:Lactulose is used in hepatic encephalopathy primarily to lower blood ammonia levels. It works by converting ammonia in the intestines into ammonium, which is then excreted³. Therefore, a decrease in ammonia levels would indicate the effectiveness of the medication.
Choice B reason:While lactulose can relieve constipation due to its laxative effect, relief of constipation is not the primary indicator of its effectiveness in treating hepatic encephalopathy³.
Choice C reason:Decreased liver enzymes are not a direct measure of lactulose's effectiveness in hepatic encephalopathy. Liver enzymes are indicators of liver function, not ammonia levels³.
Choice D reason:Relief of abdominal pain is not a specific indicator of lactulose's effectiveness in hepatic encephalopathy. The medication's primary role is to reduce ammonia levels, not to alleviate pain³.
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