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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Serum IgA levels are not typically associated with acute pancreatitis. IgA is an antibody that plays a crucial role in the immune function of mucous membranes. Changes in serum IgA levels can occur in various conditions, but they are not a characteristic finding in acute pancreatitis.
Choice B rationale
Decreased serum bilirubin is not commonly associated with acute pancreatitis. While jaundice (indicated by increased bilirubin levels) can occur in some cases of acute pancreatitis due to blockage of the bile duct, decreased bilirubin levels are not a typical finding.
Choice C rationale
Elevated serum albumin is not typically associated with acute pancreatitis. In fact, levels of albumin, a protein made by the liver, can sometimes decrease in acute pancreatitis due to inflammation and leakage of protein into the abdomen.
Choice D rationale
Elevated serum amylase is commonly associated with acute pancreatitis. Amylase is an enzyme that helps digest carbohydrates. It’s produced in the pancreas and the glands that make saliva. When the pancreas is inflamed, levels of amylase in the blood often rise.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Cooling the burn with ice water is not recommended for a client with severe burns. Ice water can cause hypothermia and further damage the skin.
Choice B rationale
Administering opioid analgesics is a key intervention for a client with severe burns. Pain management is a critical aspect of burn care.
Choice C rationale
Administering systemic antibiotics is often necessary for a client with severe burns. Burn injuries can compromise the skin’s protective barrier, making the client susceptible to infections.
Choice D rationale
Administering benzodiazepines for anxiety management can be beneficial for a client with severe burns. The experience of having a severe burn and undergoing treatment can be extremely stressful.
Choice E rationale
Positioning the head of the bed flat is not typically recommended for a client with severe burns. Elevating the head of the bed can help reduce swelling and improve respiratory function. Septic shockSeptic shock Explore
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