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 B
Explanation
Choice A rationale
Hepatitis C is not typically transmitted through saliva. It is a bloodborne virus, meaning it is most commonly transmitted through exposure to infected blood.
Choice B rationale
Hepatitis C is most commonly transmitted through exposure to infected blood. This can occur through sharing drug injection equipment, receiving a tattoo or piercing at a place with poor infection control, and other ways. Coming into contact with infected blood, such as from a used needle, is a common way the virus is transmitted.
Choice C rationale
Hepatitis C is not typically transmitted through consuming contaminated food or water. It is a bloodborne virus.
Choice D rationale
While it is possible to contract Hepatitis C by sharing personal items like toothbrushes or razors with an infected person, this is less common. The virus is most commonly transmitted through exposure to infected blood.
Correct Answer is A
Explanation
Choice A rationale
Handling the cast with the palms of the hands is recommended, especially when the cast is still wet and not fully hardened. This helps to avoid indentations and pressure points that could lead to discomfort or skin complications.
Choice B rationale
Drying the cast with a hair dryer is not typically recommended. Excessive heat can cause the cast material to weaken and can also burn the skin.
Choice C rationale
Keeping the casted leg in a dependent position is not recommended. This can lead to increased swelling and discomfort.
Choice D rationale
Covering the patient’s legs with a blanket is not specifically related to the care of a fresh cast. While it may provide comfort, it does not have a direct impact on the care or outcome of the cast.
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