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 A rationale
Discussing facility policies with coworkers. While understanding facility policies is important, it does not necessarily contribute to maintaining clinical competence.
Choice B rationale
Attending a professional conference. This is the correct answer. Professional conferences often provide opportunities for continuing education, learning about the latest research and best practices, and networking with other professionals in the field.
Choice C rationale
Joining a nurses’ union. While a union can provide support and advocacy for nurses, joining a union does not directly maintain clinical competence.
Choice D rationale
Removing expired supplies from the storage area. This is an important task for maintaining a safe and effective work environment, but it does not contribute to maintaining clinical competence.
Correct Answer is B
Explanation
Choice A rationale
Pressing down on the orbital area of the eye is not typically used as it can cause injury to the eye.
Choice B rationale
Pinching the trapezius muscle is a common method used to elicit a response from a painful stimulus in an unresponsive patient. It is considered safe and effective.
Choice C rationale
Using a 25 gauge needle to elicit a response is not typically recommended as it can cause unnecessary harm to the patient.
Choice D rationale
Eliciting a reflex with a reflex hammer is not typically used to assess responsiveness to painful stimuli. Reflex hammers are primarily used to test reflexes, not responsiveness.
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