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?
Inform the charge nurse.
Apply a dressing under the client’s nose.
Check the client’s temperature.
Test the drainage for glucose.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
A respiratory rate of 20 breaths per minute is within the normal range for an adult, indicating that the patient’s respiratory status is stable. This would be an important indicator of the effectiveness of nursing care in a patient admitted with a lower respiratory infection.
Correct Answer is B
Explanation
Choice A rationale
Avoiding intramuscular injections is not typically a component of patient education for iron deficiency anemia. Intramuscular injections do not have a direct impact on iron absorption or utilization.
Choice B rationale
Including orange juice when taking iron supplements is often recommended. The vitamin C in orange juice can enhance the absorption of iron, making it more available for the body to use. This is particularly important in iron deficiency anemia, where the body needs more iron to produce sufficient red blood cells.
Choice C rationale
Avoiding green leafy vegetables is not usually advised for patients with iron deficiency anemia. In fact, green leafy vegetables are a good source of iron and are often recommended as part of a diet for someone with this condition.
Choice D rationale
Avoiding live immunizations is not typically a part of patient education for iron deficiency anemia. The condition does not affect the immune response to vaccines, nor do vaccines interfere with iron absorption or utilization.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.