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 B

Explanation

A) Treatment plan will need to be changed to achieve the desired effect:
The decrease in the carcinoembryonic antigen (CEA) levels from 50 ng/mL to 10 ng/mL suggests that the cancer is responding to the current treatment, not that the treatment plan needs to be changed. A drop in CEA levels typically indicates a positive response to treatment, such as chemotherapy, in reducing the number or size of cancer cells.

B) Cancer treatment is having the desired effect on killing cancer cells:
Carcinoembryonic antigen (CEA) is a tumor marker that is often elevated in individuals with certain cancers, particularly colorectal cancer. A decrease in CEA levels, as noted in this case (from 50 ng/mL to 10 ng/mL), usually signifies that the treatment is successfully targeting the cancer and reducing the tumor burden. This drop suggests that the chemotherapy is effectively killing cancer cells and reducing the size or activity of the tumor.

C) Client is at greater risk for tumor lysis syndrome:
Tumor lysis syndrome typically occurs when large numbers of cancer cells die rapidly, releasing their intracellular contents into the bloodstream, which can lead to metabolic disturbances like hyperkalemia, hyperphosphatemia, and renal failure. It is more common in aggressive hematologic cancers, such as leukemia or lymphoma, and typically presents with a rapid rise in tumor marker levels, not a decrease.

D) Cancer has increased size and metastatic sites:
An increase in tumor size or the development of metastatic sites would typically result in an increase in CEA levels, not a decrease. Since CEA levels have dropped, it is more likely that the cancer is shrinking or responding to the current treatment. This finding is more indicative of a positive response rather than disease progression.

A. assess the patient's neurological status and repeat vital signs B. ask the patient care tech to check on the patient. C. place the client in reverse Trendelenburg position. D. administer intravenous (tv) fluids to increase cardiac output.

Correct Answer is A

Explanation

A) Assess the patient's neurological status and repeat vital signs:
In patients with a spinal cord injury (SCI) at T1, autonomic dysreflexia or neurogenic shock can lead to unstable vital signs, including hypotension and bradycardia. The most immediate concern in this scenario is to determine if the patient is experiencing neurogenic shock, which can result from the loss of sympathetic nervous system function below the level of the injury. By assessing the patient’s neurological status (such as checking for changes in motor function, sensation, or level of consciousness) and repeating vital signs, the nurse can gather the necessary data to make informed decisions about further interventions.

B) Ask the patient care tech to check on the patient:
While the patient care tech can assist with tasks, this is not the priority action. The nurse must immediately assess the patient's condition, particularly given the vital sign changes and the potential for a life-threatening situation like neurogenic shock. The nurse's clinical judgment and expertise are required to evaluate the situation appropriately.

C) Place the client in reverse Trendelenburg position:
Placing the patient in reverse Trendelenburg may help with hypotension in certain situations, but it is not the priority intervention for someone with a spinal cord injury at T1. In cases of neurogenic shock or autonomic dysreflexia, positioning alone will not correct the underlying issue.

D) Administer intravenous (IV) fluids to increase cardiac output:
While IV fluids may be necessary to treat hypotension in some situations, the nurse must first assess the patient’s neurological status and repeat vital signs to determine the cause of the hypotension and bradycardia. Administering IV fluids without understanding the underlying cause could be inappropriate or even harmful, particularly if the low blood pressure is related to neurogenic shock, which requires careful management.

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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

The nurse is reviewing lab results for a client receiving chemotherapy for the treatment of cancer. The nurse notes the carcinoembryonic antigen (CEA) was previously 50 ng/ mL and is now 10 ng/mL (normal range 0-2.5 ng/mL) The nurse is aware this finding indicates the:

Correct Answer is B

Explanation

The nurse is caring for a patient who sustained a spinal cord injury (SCI) at T1. The alarm on the monitor sounds because the patient's blood pressure is 86/50 and the heart rate is 44. The nurse's priority action would be to:

Correct Answer is A

Explanation

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