A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

Test the drainage for the halo sign.

Ask the client to blow his nose.

Notify the physician.

Suction the nostril.

Answer and Explanation

The Correct Answer is A

Choice A reason:Testing the drainage for the halo sign is the first action the nurse should take, as clear drainage from the nose following a basal skull fracture could indicate a cerebrospinal fluid (CSF) leak, which contains glucose.

Choice B reason:Asking the client to blow his nose could potentially increase the risk of infection or worsen a CSF leak and is not recommended as a first action.

Choice C reason:While notifying the physician is important, it should be done after confirming whether the drainage is CSF, which would require immediate medical intervention.

Choice D reason:Suctioning the nostril is not the first action to take, as it could potentially disrupt the site of the leak and is not diagnostic of a CSF leak.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Administering oxygen therapy is the first and immediate intervention for a client with a pulmonary embolism to address hypoxemia.

Choice B reason: Starting an IV infusion of Lactated Ringer's is important for fluid resuscitation but is not the first intervention for pulmonary embolism.

Choice C reason: Initiating cardiac monitoring is important for observing the client's heart function but comes after ensuring the client is receiving adequate oxygen.

Choice D reason: Giving morphine IV may be used for pain management in pulmonary embolism but is not the first-line intervention.

A. Atropine B. Furosemide C. Heparin D. Dexamethasone

Correct Answer is C

Explanation

Choice A reason: Atropine is not typically used for the treatment of pulmonary embolism. It is an anticholinergic drug that is primarily used to treat bradycardia (slow heart rate) and as part of the management of organophosphate poisoning. It does not have a role in the management of pulmonary embolism, which requires anticoagulation to prevent further clot formation.

Choice B reason: Furosemide is a loop diuretic commonly used to treat fluid overload conditions such as heart failure or edema. While it can help relieve symptoms associated with fluid accumulation, it does not treat the underlying cause of a pulmonary embolism, which is a blood clot in the pulmonary arteries.

Choice C reason: Heparin is an anticoagulant medication that is commonly used in the initial treatment of pulmonary embolism. It works by preventing the formation of new blood clots and stopping existing clots from getting bigger. Heparin is often administered intravenously or subcutaneously and is a key component in the management of pulmonary embolism.

Choice D reason: Dexamethasone is a corticosteroid that is used to reduce inflammation in various conditions, such as allergic reactions, asthma, and certain types of arthritis. It is not used as a primary treatment for pulmonary embolism, as it does not have anticoagulant properties.

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

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

Correct Answer is A

Explanation

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

Correct Answer is C

Explanation

The healthcare provider prescribes lactulose for a patient with hepatic encephalopathy. What will the nurse assess to determine the effectiveness of this medication?

The nurse is caring for a client who has a small bowel obstruction. When teaching the student nurse about this condition, the nurse will include which of the following findings that are consistent with the diagnosis? (Select all that apply).

A client is admitted to the hospital with suspected rheumatic endocarditis. Which of the following laboratory tests would assist in confirming the diagnosis?

A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?

A client in the emergency department has suspected stomach perforation due to a peptic ulcer. The nurse is completing the assessment and should expect which of the following findings? (Select all that apply).

A nurse is assessing a client who has left-sided heart failure. Which of the following clinical manifestations will the nurse expect?

A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). Which of the following medications should the nurse plan to administer after the initial acute phase to manage the client's pain and anxiety?

A nurse is teaching a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client?