How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is attending to a client who has suffered a basal skull fracture.

During the morning hygiene care, the nurse observes a thin clear drainage coming from the client’s right nostril.

What should be the nurse’s immediate action?

A.

Inform the charge nurse.

B.

Apply a dressing under the client’s nose.

C.

Check the client’s temperature.

D.

Test the drainage for glucose.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Informing the charge nurse is an important step, but it is not the immediate action. The nurse should first assess the situation before escalating it.
Choice B rationale
Applying a dressing under the client’s nose might help manage the drainage, but it does not address the underlying issue. The drainage could be cerebrospinal fluid (CSF), which is a serious condition that needs immediate attention.
Choice C rationale
Checking the client’s temperature is a general assessment and does not directly relate to the symptom of clear nasal drainage.
Choice D rationale
Testing the drainage for glucose is the correct action. Clear nasal drainage after a basal skull fracture could be a sign of a cerebrospinal fluid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help confirm if it’s CSF34.
 


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is D

Explanation

Choice A rationale
While fatigue is a common symptom of Hodgkin’s disease, it is not the most urgent symptom to address when there is significant cervical lymph node enlargement.
Choice B rationale
Pain can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice C rationale
Fever can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice D rationale
Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Stridor may indicate a serious condition affecting the throat or larynx (voice box). With significant cervical lymph node enlargement, the lymph nodes may be pressing on the airway, causing stridor. This is a medical emergency and should be addressed first.

Correct Answer is B

Explanation

Choice A rationale
While it’s true that electrical burns can cause more skin damage than what can be seen on the skin, this statement does not fully address the client’s misconception about the severity of their burn.
Choice B rationale
This is the best response because it directly addresses the client’s misconception and provides accurate information. Electrical burns can indeed have small amounts of skin damage but cause more extensive damage beneath the skin. This is because the electrical current can pass through the body and damage internal tissues and organs, even if the visible wound on the skin is small.
Choice C rationale
While electrical burns can cause reddened or purplish skin, they do not typically cause blistering. Furthermore, this statement does not address the client’s misconception about the severity of their burn.
Choice D rationale
This statement is incorrect. Electrical burns are not typically minor. They can cause serious internal injuries and complications, even if the visible wound on the skin is small.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register