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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Removing objects is contraindicated, as it can worsen the injury.
B. Stabilizing the object and covering it prevents further injury until medical evaluation, which is critical in cases of eye trauma. Moving or removing a foreign body could lead to additional damage.
C. Providing a light meal is not directly related to managing eye trauma and does not address the immediate concern.
D. Blowing the nose could increase intraocular pressure, potentially worsening the injury.
Correct Answer is ["C","D","E"]
Explanation
A. Padded tongue blades are not appropriate for seizure management and are not necessary in this context.
B. Soft wrist restraints are not required in this scenario unless otherwise indicated.
C. An Ambu bag and oxygen are crucial for respiratory support, especially if the patient has compromised breathing due to spinal cord injury.
D. Wrenches should be readily available to quickly remove halo traction in case of an emergency, such as if the patient's airway needs to be accessed.
E. An oral suction tube (Yankauer) is important for managing oral secretions, which can be challenging for patients with limited mobility.
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