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

Administer antibiotics due to increased risk of infection

Prevent the drainage by applying a pressure dressing

Hang intravenous (IV) fluids to replace fluids lost

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

Answer and Explanation

The Correct Answer is D

A. Antibiotics may be necessary if infection is confirmed, but this is not the priority action.

B. Applying a pressure dressing could increase intracranial pressure or worsen the injury.

C. IV fluids can be helpful in managing shock but are not directly related to CSF leakage management.

D. Yellowish fluid from the ear, which creates a "halo" or yellow ring around it on gauze, may indicate cerebrospinal fluid (CSF) leakage. This is a sign of a potential skull fracture and requires prompt provider notification. Allowing the fluid to drain and collecting it can provide necessary information about the injury.

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Correct Answer is A

Explanation

A. Standard precautions should be used for all patients, including those with AIDS, as they are designed to prevent the transmission of infections regardless of the patient's diagnosis. This includes the use of gloves, hand hygiene, and proper disposal of sharps.

B. Droplet precautions are specific to diseases that are spread through respiratory droplets, which is not the primary concern in AIDS management.

C. Contact precautions are used for infections that can be transmitted through direct contact with the patient or contaminated surfaces, but are not routinely required for AIDS patients unless they have co-infections.

D. Behavioral precautions are not a recognized category for infection control in clinical settings.

A. Suction the patient to minimize secretions B. Continue with the assessment and document the finding C. Notify the physician and raise HOB to 35-45 degrees D. Lower the head of the bed and pad the side rails

Correct Answer is C

Explanation

A. Suctioning can increase ICP due to the Valsalva response and should only be done if absolutely necessary.

B. Documenting without intervention could lead to worsening of the patient's condition.

C. Notifying the physician and raising the head of the bed helps to reduce ICP by promoting venous drainage. An ICP of 30 mmHg is critically high, requiring immediate intervention to prevent further damage.

D. Lowering the head of the bed can increase ICP further; head elevation is recommended to improve cerebral drainage.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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