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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Elevating the patient's buttocks off the bed is appropriate in Bryant's traction, ensuring effective countertraction and alignment of the fractured bone. This position doesn't compromise traction function.
Choice B rationale:
Proper weight suspension, free of interference, prevents inadequate traction. This maintains the pulling force needed for fracture reduction and immobilization. No compromise is indicated here.
Choice C rationale:
Flexing the patient's hips at a 90-degree angle promotes proper body alignment. Although this angle might vary depending on the specific type of traction, it's not an immediate indication of traction compromise.
Choice D rationale:
Placing a knot in the rope against a pulley impedes the smooth functioning of the traction system. This could lead to a decrease in the applied traction force, potentially compromising fracture alignment and healing.
Correct Answer is D
Explanation
Choice D rationale:
Preschool-aged children may fear pain and bleeding, and applying a small dressing after venipuncture helps alleviate anxiety. It provides a sense of control and comfort, as the child perceives their active participation in caring for the site.
Choice A rationale:
Showing the needle and syringe might intensify anxiety in the child, making venipuncture more distressing. It's important to minimize any distress during the procedure.
Choice B rationale:
Allowing the child to help cleanse the site could lead to more anxiety as the child might interpret it as their own responsibility for the procedure.
Choice C rationale:
Encouraging the child to show the site to adults may not be reassuring for the child and could potentially exacerbate their apprehension.
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