What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?

Compress the nares.

Administer decongestant for postnasal drip.

Tilt the head back.

Collect the drainage.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Compressing the nares is not the first action that the nurse should take, as it may increase intracranial pressure and worsen the head injury.

Choice B Reason: Administering decongestant for postnasal drip is not the first action that the nurse should take, as it may mask the signs of cerebrospinal fluid (CSF) leakage and delay diagnosis and treatment.

Choice C Reason: Tilting the head back is not the first action that the nurse should take, as it may cause aspiration of CSF or blood and increase the risk of infection.

Choice D Reason: Collecting the drainage is the first action that the nurse should take, as it helps to identify if the drainage is CSF or nasal secretions, and to monitor the amount and characteristics of the drainage.

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Correct Answer is A

Explanation

Choice A Reason: Following a high-fiber diet to establish bowel regularity is an appropriate instruction for a client who has hemorrhoids, as it helps to soften stools and reduce straining and pressure on hemorrhoids.

Choice B Reason: Using a stimulant laxative to prevent constipation is not an appropriate instruction for a client who has hemorrhoids, as it may cause diarrhea, dehydration, or electrolyte imbalance.

Choice C Reason: Cleaning the anal area after bowel movements with alcohol-based wipes is not an appropriate instruction for a client who has hemorrhoids, as it may irritate, dry, or damage hemorrhoidal tissue.

Choice D Reason: Limiting the intake of fruit to prevent loose stools is not an appropriate instruction for a client who has hemorrhoids, as fruit is a good source of fiber and fluid that can help prevent constipation and hemorrhoids.

A. Irrigate the fistula with 3 mL of normal saline solution. B. Flush the fistula with 1 mL of heparin solution once per shift. C. Infuse 50 mL of normal saline once per 24 hours. D. Palpate for a vibrating sensation at the fistula site.

Correct Answer is D

Explanation

Choice A Reason: Irrigating the fistula with 3 mL of normal saline solution is not a correct way to assess the patency of the fistula, as it may cause bleeding, infection, or dislodgement of the fistula.

Choice B Reason: Flushing the fistula with 1 mL of heparin solution once per shift is not a correct way to assess the patency of the fistula, as it may cause clotting, infection, or allergic reaction.

Choice C Reason: Infusing 50 mL of normal saline once per 24 hours is not a correct way to assess the patency of the fistula, as it may cause fluid overload, hypertension, or edema.

Choice D Reason: Palpating for a vibrating sensation at the fistula site is a correct way to assess the patency of the fistula, as it indicates that there is adequate blood flow through the fistula. This sensation is also known as a thrill.

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What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to reinforce teaching with a client who has hemorrhoids. Which of the following information should the nurse plan to include in the instructions?

Correct Answer is A

Explanation

I can help you with formatting and editing the text. Here are the edited texts: Text 1: A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula?

Correct Answer is D

Explanation

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