A 3-year-old patient who is admitted to the hospital for the treatment of a skull fracture has clear liquid draining from his nose. In consideration of the patient's injury, which action should the nurse take initially?

Give the patient a soft tissue to clean up the drainage.

Check the drainage for glucose content.

Obtain a specimen of the drainage for culture and sensitivity.

Ask the father if the patient had nasal drainage before his injury.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Giving the patient a soft tissue is not the initial action to take when dealing with clear liquid drainage from the nose. Assessing the content of the drainage is more crucial for appropriate management.

Choice B rationale:

Checking the drainage for glucose content is essential because the presence of glucose indicates that the drainage is cerebrospinal fluid (CSF), which can occur with a skull fracture that involves the base of the skull.

Choice C rationale:

Obtaining a specimen of the drainage for culture and sensitivity is important, but it is not the initial action. Confirming the nature of the drainage takes precedence.

Choice D rationale:

Asking the father about nasal drainage before the injury is not as relevant as assessing the current drainage, which could be indicative of a CSF leak.

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Correct Answer is B

Explanation

Weighing the patient's wet diapers prior to discarding them.

Choice A rationale:

Inserting an indwelling urinary catheter is invasive and not appropriate for a non-toilet-trained 2-year-old unless medically necessary.

Choice B rationale:

Weighing wet diapers is the most accurate way to measure urine output in a young child who isn't toilet trained. This method provides essential information for assessing hydration and kidney function.

Choice C rationale:

Sitting the patient on the bedpan every two hours is suitable for older children but may not be effective or tolerable for a 2-year-old.

Choice D rationale:

Applying a pediatric urine collection device is an option, but it might not be as accurate as weighing wet diapers and may cause discomfort for the child.

A. Educating caregivers on sensory impairment. B. Preventing infection. C. Correction of joint contractures. D. Measuring daily head circumference.

Correct Answer is B

Explanation

Choice A rationale:

While educating caregivers on sensory impairment is important for an infant with myelomeningocele, preventing infection takes precedence as the priority nursing intervention.

Choice B rationale:

The correct answer. Preventing infection at the site of the myelomeningocele is crucial to avoid potentially life-threatening complications, such as meningitis. The exposed neural tissue poses a significant infection risk.

Choice C rationale:

Correcting joint contractures is important but is a secondary concern compared to preventing infection, which can have more immediate and severe consequences.

Choice D rationale:

Measuring daily head circumference is important to monitor for hydrocephalus in these infants, but preventing infection remains the higher priority.

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A 3-year-old patient who is admitted to the hospital for the treatment of a skull fracture has clear liquid draining from his nose. In consideration of the patient's injury, which action should the nurse take initially?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is to record the intake and output of a 2-year-old patient. The patient is not toilet trained. Which measure would be most appropriate to include in the patient's plan of care?

Correct Answer is B

Explanation

Which is the priority nursing intervention for an infant diagnosed with myelomeningocele?

Correct Answer is B

Explanation

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