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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is D
Explanation
Choice A Reason: Ice cream is not a good food choice for a client who has cholecystitis, as it is high in fat and may trigger gallbladder pain or inflammation.
Choice B Reason: Blueberry muffin is not a good food choice for a client who has cholecystitis, as it may contain butter, oil, or eggs that are high in fat and may aggravate gallbladder symptoms.
Choice C Reason: Macaroni and cheese is not a good food choice for a client who has cholecystitis, as it is high in fat and cholesterol and may cause gallstone formation or obstruction.
Choice D Reason: Roast turkey is a good food choice for a client who has cholecystitis, as it is low in fat and high in protein and may help to prevent gallbladder attacks.
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