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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Tucking small disposable diapers under the cast edges in the buttock area may cause discomfort to the patient and could also potentially disrupt the cast alignment. It may also not effectively prevent soiling.
Choice B rationale:
Lining the edges of the cast with absorbent pads and securing with tape might not fully protect the cast from urine and feces. The absorbent pads could still allow some leakage and contamination.
Choice C rationale:
Placing a large cloth diaper over the perineal cutout area provides comprehensive protection against urine and feces soiling the cast. This method ensures that the cast remains clean and dry.
Choice D rationale:
Laying the client on a disposable pad with the perineal area exposed to air is not a practical solution. It does not offer adequate protection for the cast, and exposing the perineal area to air could lead to discomfort and potential complications.
Correct Answer is A
Explanation
Choice A rationale:
Monitoring the apical pulse is of the highest priority for a patient with a myelomeningocele preoperatively. A myelomeningocele is a neural tube defect that can lead to neurologic complications. Monitoring the apical pulse every hour helps detect any signs of cardiac distress or neurological compromise, allowing prompt intervention.
Choice B rationale:
Maintaining the patient in a prone position is not the priority in this situation. While positioning can be important, monitoring vital signs takes precedence over positioning.
Choice C rationale:
Providing sensory stimulation is important for the patient's overall well-being, but it's not the highest priority preoperatively. Monitoring vital signs and assessing for potential complications take precedence.
Choice D rationale:
Keeping a strict record of the patient's intake and output is important for general care, but it's not the highest priority in the immediate preoperative period. Monitoring vital signs and detecting signs of distress come first.
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