A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?

Edematous bruise on forehead

Client disoriented to place

Heart rate 110/min and regular

Small drops of clear ﬂuid in left ear

Answer and Explanation

The Correct Answer is D

The nurse should immediately report small drops of clear ﬂuid in the left ear to the charge nurse. This finding could indicate a cerebrospinal ﬂuid (CSF) leak, which can occur as a result of a head injury. A CSF leak can be a serious medical condition that requires immediate attention.

An edematous bruise on the forehead, client disorientation to place, and a heart rate of 110/min and regular are also important findings that the nurse should report to the charge nurse. However, these findings are not as urgent as the presence of small drops of clear ﬂuid in the left ear.

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Correct Answer is C

Explanation

The priority intervention for the nurse to implement for a newly-admitted client who has acute osteomyelitis is antibiotic therapy. Osteomyelitis is an inﬂammatory condition of bone secondary to an infectious process¹. Antibiotics are the primary treatment option and should be tailored based on culture results and individual patient factors.

a. Optimal nutrition and hydration is important but not the priority intervention.
b. Surgical debridement of necrotic tissue may be necessary but is not the priority intervention.
d. Antipyretic therapy may be necessary but is not the priority intervention.

A. Apply the elastic compression dressing tight enough so the toes and ankle become numb. B. Place moderate weight on the aﬀected leg when walking. C. Elevate the aﬀected ankle to the level of the heart. D. Apply heat during the first 24 hr.

Correct Answer is C

Explanation

The nurse should instruct the client to elevate the aﬀected ankle to the level of the heart. Elevation helps to reduce swelling and pain by promoting venous return and decreasing blood ﬂow to the injured area. This is an important part of the RICE (Rest, Ice, Compression, Elevation) method for treating sprains and strains.

a. The elastic compression dressing should not be applied so tight that it causes numbness in the toes and ankle.
b. The client should avoid placing weight on the aﬀected leg when walking until advised by a healthcare provider.
d. Heat should not be applied during the first 24 hours after a sprain as it can increase swelling and inﬂammation.

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A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a newly-admited client who has acute osteomyelitis. Which of the following interventions is the priority for the nurse to implement?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has an ankle sprain. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)

A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?

A nurse is caring for a client who has osteoporosis and is taking calcium carbonate. The nurse should monitor the client for which of the following adverse eﬀects?

A nurse is collecting data from a client who has a short arm cast for a fractured wrist. Which of the following findings indicates impaired venous return in the aﬀected arm?

A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is collecting data from a client who has a traumatic head injury. Which of the following findings should the nurse report to the provider immediately?

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?