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 D
Explanation
A. Bradycardia is possible due to autonomic dysfunction but is not the leading cause of death.
B. Sepsis can occur due to immobility and pressure injuries but is secondary to respiratory compromise.
C. Hypertension is not directly linked to high cervical spine injuries and is less common than respiratory issues in this setting.
D. Respiratory compromise is the primary cause of complications or death in patients with a high cervical spine injury (C-3 and above) due to loss of innervation to the diaphragm and intercostal muscles, which impairs spontaneous breathing. Mechanical ventilation is often required to maintain adequate oxygenation.
Correct Answer is D
Explanation
A. Establishing IV access may be necessary if hypotension persists but is not the initial priority.
B. Bladder distension assessment is essential for managing autonomic dysreflexia in SCI patients; however, symptoms here suggest orthostatic hypotension rather than autonomic dysreflexia.
C. Rescheduling therapy may be considered if dizziness persists, but it does not address the immediate concern.
D. Lowering the head of the bed and obtaining vital signs can help stabilize blood pressure and monitor for orthostatic hypotension, which is common in patients with SCI due to autonomic dysfunction. This intervention helps to prevent syncope.
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