The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.
The nurse notices a yellow stain around fluid dripping from the patient's ear.
The nurse's priority intervention will be as follows:

Prevent the drainage by applying a pressure dressing.

Allow fluid to drain from the patient's ear onto gauze and notify the provider.

Hang intravenous (IV) fluids to replace fluids lost.

Administer antibiotics due to increased risk of infection.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Applying pressure to prevent drainage could force cerebrospinal fluid (CSF) back into the cranial cavity, increasing infection risk and intracranial pressure, potentially worsening brain injury. CSF leakage requires non-obstructive handling.

Choice B rationale

Allowing fluid to drain onto gauze prevents build-up of intracranial pressure while assessing for halo sign, indicating CSF leakage. Yellow staining reflects glucose presence in CSF, confirming dura mater damage.

Choice C rationale

Intravenous fluids manage hypovolemia but are not prioritized for trauma patient brain injuries. Replacing lost CSF requires specific medical intervention rather than fluid volume adjustments alone.

Choice D rationale

Antibiotics treat infections but are not first priority for confirmed CSF leakage, which demands careful monitoring of drainage to prevent neurological damage. Post-intervention antibiotics may be necessary.

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Free Nursing Study Resources

Correct Answer is ["66.7"]

Explanation

Step 1 is (1600 mL ÷ 24 hours).

Answer is 66.7 mL/hr.

A. Hold the feeding if the client has soft brown stools and is passing flatus. B. Dilute each medication with 5% dextrose in water (D5W) and flush with at least 30 mL. C. Discuss the order with the prescriber if the client's abdomen is distended with hypoactive bowel sounds and RLQ tenderness. D. Check for residual enteral formula prior to administration.

Correct Answer is C

Explanation

Choice A rationale

Soft stools and flatus indicate proper gastrointestinal function, suggesting tolerance to feeding. With no adverse symptoms, it is not scientifically valid to hold enteral feeding based on these findings alone.

Choice B rationale

Diluting medications with D5W and flushing ensures patency but does not address potential complications like abdominal distention or bowel sounds. RLQ tenderness must first be evaluated for safety.

Choice C rationale

Abdomen distention with hypoactive bowel sounds and RLQ tenderness suggests possible ileus or bowel obstruction. Discussing this condition with the prescriber ensures safe feeding practices and prevents worsening complications.

Choice D rationale

Residual formula checks are relevant for gastric, not jejunostomy, feeding. Scientific practice discourages assessing residual in jejunostomy feeding as the tube bypasses the stomach.

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The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.The nurse notices a yellow stain around fluid dripping from the patient's ear.The nurse's priority intervention will be as follows:

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer 1600 mL of total parental nutrition (TPN) over 24 hours. The nurse should set the IV pump to deliver how many mL/hr?

Correct Answer is ["66.7"]

Explanation

A client with a severe stroke has been prescribed enteral feedings via a jejunostomy tube.For safe administration, the nurse should:

Correct Answer is C

Explanation

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The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.
The nurse notices a yellow stain around fluid dripping from the patient's ear.
The nurse's priority intervention will be as follows: