A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first?

Test the drainage for glucose.

Take the client's temperature.

Notify the charge nurse.

Place a dressing under the client's nose.

Answer and Explanation

The Correct Answer is A

The first action the nurse should take is to test the drainage for glucose. Clear drainage from the nose following a basal skull fracture could indicate a cerebrospinal ﬂuid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help determine if it is CSF.

b. Taking the client's temperature is not the first action the nurse should take.
c. Notifying the charge nurse is important but not the first action the nurse should take.
d. Placing a dressing under the client's nose is not the first action the nurse should take.

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Correct Answer is C

Explanation

The highest priority nursing intervention for a client who is unconscious following a stroke is to suction saliva from the client's mouth. This can help prevent aspiration and maintain a patent airway, which is essential for the client's survival.

Performing passive range of motion on each extremity, recording the client's intake and output, and monitoring the client's electrolyte levels are also important nursing interventions for this client. However, these interventions are not as high of a priority as maintaining a patent airway.

A. Hyaluronic acid B. Ibuprofen C. Acetaminophen D. Celecoxib

Correct Answer is C

Explanation

The nurse should anticipate that the provider will initially prescribe acetaminophen to the client who has a new diagnosis of osteoarthritis. Acetaminophen (Tylenol, others) has been shown to help some people with osteoarthritis who have mild to moderate pain². It is often used as a first-line treatment for osteoarthritis pain.

a. Hyaluronic acid is not typically the first medication prescribed for osteoarthritis.
b. Ibuprofen may be prescribed for osteoarthritis but is not typically the first medication prescribed.
d. Celecoxib may be prescribed for osteoarthritis but is not typically the first medication prescribed.

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A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?

Correct Answer is C

Explanation

A nurse in a clinic is collecting data from an older adult client who has a new diagnosis of osteoarthritis. Which of the following medications should the nurse anticipate the provider will initially prescribe to the client?

Correct Answer is C

Explanation

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