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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A Reason: Encouraging deep-breathing exercises is not the most appropriate nursing intervention, as it may not reduce fatigue and may increase respiratory effort.

Choice B Reason: Providing a relaxing warm bath is not the most appropriate nursing intervention, as it may worsen fatigue and increase the risk of heat intolerance and dehydration.

Choice C Reason: Scheduling periods of rest in between activities is the most appropriate nursing intervention, as it helps to conserve energy, prevent exhaustion, and promote recovery.

Choice D Reason: Administering multivitamins is not the most appropriate nursing intervention, as it may not improve fatigue and may cause adverse effects or interactions with other medications.

A. You will remain NPO for 8 hours before the procedure. B. A flexible tube is introduced through the nose during the procedure. C. During the procedure, a contrast dye will be administered via IV. D. You will be awake while the procedure is performed.

Correct Answer is A

Explanation

Choice A Reason:For an endoscopy, the client must remain NPO (nothing by mouth) for 6 to 8 hours before the procedure to reduce the risk of aspiration and ensure a clear view of the esophagus and stomach.

Choice B Reason: A flexible tube is not introduced through the nose during the procedure, but through the mouth and down the esophagus.

Choice C Reason: During the procedure, a contrast dye is not administered via IV, but a sedative and an anesthetic spray are given to help you relax and numb your throat.

Choice D Reason: Clients undergoing an EGD typically receive moderate sedation (such as midazolam or propofol) to help them relax. They are usually drowsy and unaware during the procedure.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 client with multiple sclerosis is seen by the home health nurse and complains of severe fatigue. Which of the following is the most appropriate nursing intervention?

Correct Answer is C

Explanation

A nurse is reinforcing teaching about an endoscopy with a client who has dysphagia. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

A client admitted to a medical-surgical unit for surgery has a history of Cushing's syndrome. Which physical assessment finding would the nurse expect to observe?

A nurse is caring for a client who had a cholecystectomy and has a T-tube drain. Which of the following actions should the nurse take?

A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease?

A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client?

A client's stool is clay in color. What additional information should the nurse obtain from this client? Select all that apply.

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?

A nurse is monitoring a client who is receiving chemotherapy and has a platelet count of 20,000 mm3. Which of the following findings should the nurse identify as the priority?

A nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed and the pulse and respiratory rate are increased from the client's baseline. The nurse would first take which action?