The nurse notices a yellow stain around fluid dripping from a patient’s ear who sustained a traumatic brain injury. The nurse's priority intervention will be as follows:

prevent the drainage by applying a tight pressure dressing

administer antibiotics due to increased risk of infection

allow fluid to drain from the patient's car onto gauze and notify

hang intravenous (IV) fluids to replace fluids lost and prevent dehydration

Answer and Explanation

The Correct Answer is C

A) Prevent the drainage by applying a tight pressure dressing:
Applying a tight pressure dressing is not the appropriate intervention in this case. The presence of fluid draining from the ear, particularly a yellow stain, could indicate cerebrospinal fluid (CSF) leakage, which is a potential sign of a skull fracture or traumatic brain injury (TBI) involving the base of the skull. Applying a tight pressure dressing could potentially increase pressure or cause further injury.

B) Administer antibiotics due to increased risk of infection:
While there is an increased risk of infection with a CSF leak, antibiotics should not be administered immediately unless there is clear evidence of an infection. The priority action is to identify whether the fluid is CSF, as antibiotics alone will not address the underlying issue of a CSF leak. The nurse should allow the fluid to drain, collect a sample, and notify the healthcare provider for further assessment, which may include imaging or testing for the presence of CSF.

C) Allow fluid to drain from the patient's ear onto gauze and notify the healthcare provider:
The yellow stain around the fluid dripping from the patient's ear suggests the possibility of CSF leakage, a sign of a skull base fracture. CSF leakage may occur after a traumatic brain injury and should be handled carefully. The nurse's priority action is to allow the fluid to drain onto gauze to prevent the buildup of pressure and to prevent further leakage into the ear canal. The nurse should also immediately notify the healthcare provider for further evaluation and management.

D) Hang intravenous (IV) fluids to replace fluids lost and prevent dehydration:
While IV fluids may be necessary in some cases for patients with trauma, the priority in this situation is to identify the source and nature of the drainage. If the fluid is CSF, it may be important to manage the leak appropriately rather than focusing solely on replacing fluids. The nurse should first confirm whether the fluid is CSF and notify the healthcare provider for further assessment and management. Replacing fluids may be necessary, but it is not the immediate priority.

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Correct Answer is C

Explanation

A) "I agree. Sometimes the adverse effects can be worse than the disease":
While it's important for the nurse to acknowledge the client's concerns, making this statement may not be helpful in this situation. It could unintentionally reinforce fear and anxiety, implying that the chemotherapy's side effects may be worse than the disease itself, which is not always the case. Instead, the nurse should engage the client in a discussion to explore the specific concerns, allowing for tailored support and information.

B) "Someone from the American Cancer Society will be here soon to answer your questions":
While the American Cancer Society can provide valuable support and resources, referring the client to someone else to answer their questions can feel dismissive. The nurse should take the opportunity to listen to the client’s concerns and provide immediate reassurance or information. Direct involvement in the discussion builds trust and allows for more immediate emotional and psychological support.

C) "What is it about the adverse effects that concern you?":
This response is the most appropriate as it encourages the client to express their specific concerns. By asking the client to clarify their worries, the nurse can provide more accurate information, address misunderstandings, and offer reassurance. This open-ended question helps the nurse understand the client's emotions and individual needs, which allows for a more personalized approach in managing anxiety and providing education about the chemotherapy treatment.
D) "I will have your provider discuss the adverse effects with you before the treatment begins":
While it is important for the healthcare provider to discuss the treatment plan and potential side effects, the nurse should not defer the conversation entirely. The nurse plays an essential role in providing ongoing support, educating the client, and answering questions. The nurse can start the conversation and provide information about the common side effects of chemotherapy, offering the opportunity for further discussion with the provider as needed. Deferring the conversation might leave the client feeling unsupported.

A. respiratory acidosis B. metabolic acidosis C. metabolic alkalosis D. respiratory alkalosis

Correct Answer is D

Explanation

A) Respiratory acidosis:
Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO2) in the blood, leading to a decrease in pH. In the given blood gas values, the PaCO2 is 28 mmHg, which is lower than the normal range (35-45 mmHg), indicating that CO2 is being exhaled more than usual, not accumulating.

B) Metabolic acidosis:
Metabolic acidosis results from a decrease in bicarbonate (HCO3-) or an increase in acid in the body. However, in the provided values, the bicarbonate (HCO3-) is normal at 24 mEq/L, and the pH is elevated at 7.51, indicating alkalosis rather than acidosis

C) Metabolic alkalosis:
Metabolic alkalosis occurs when there is an increase in bicarbonate levels or excessive loss of acids, often associated with vomiting or diuretic use. However, in this case, the bicarbonate level (HCO3-) is normal, and the pH is more consistent with alkalosis due to respiratory factors, not metabolic causes.

D) Respiratory alkalosis:
Respiratory alkalosis occurs when there is excessive exhalation of CO2, leading to a rise in blood pH (alkalosis). The pH is 7.51, which is above the normal range (7.35-7.45), indicating alkalosis. Additionally, the PaCO2 is low at 28 mmHg, which suggests that the client is hyperventilating and exhaling too much CO2, confirming respiratory alkalosis as the correct interpretation.

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The nurse notices a yellow stain around fluid dripping from a patient’s ear who sustained a traumatic brain injury. The nurse's priority intervention will be as follows:

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Naxlex Comprehensive Predictor Exams

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Explanation

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