A nurse is attending to a client who has suffered a basal skull fracture.

During the morning hygiene care, the nurse observes a thin clear drainage coming from the client’s right nostril.

What should be the nurse’s immediate action?

Inform the charge nurse.

Apply a dressing under the client’s nose.

Check the client’s temperature.

Test the drainage for glucose.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Informing the charge nurse is an important step, but it is not the immediate action. The nurse should first assess the situation before escalating it.
Choice B rationale
Applying a dressing under the client’s nose might help manage the drainage, but it does not address the underlying issue. The drainage could be cerebrospinal fluid (CSF), which is a serious condition that needs immediate attention.
Choice C rationale
Checking the client’s temperature is a general assessment and does not directly relate to the symptom of clear nasal drainage.
Choice D rationale
Testing the drainage for glucose is the correct action. Clear nasal drainage after a basal skull fracture could be a sign of a cerebrospinal fluid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help confirm if it’s CSF34.

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Correct Answer is C

Explanation

Choice A rationale
While pain at the burn site can be a symptom of many conditions, it is not a specific indicator of a local infection in the burned area.
Choice B rationale
Edematous hands can be a sign of many conditions, including burns, but they are not a specific indicator of a local infection in the burned area.
Choice C rationale
A foul odor from the burned area is a strong indicator of a local infection. Bacteria and other microorganisms that cause infections can produce waste products that have a foul smell.
Choice D rationale
A temperature of 99.8 degrees Fahrenheit is within the normal body temperature range and is not a specific indicator of a local infection in the burned area.

Correct Answer is ["15"]

Explanation

Step 1 is to determine the amount of clindamycin palmitate in each mL of the oral suspension. This is done by dividing the total amount of clindamycin palmitate in 5 mL by 5. So, 75 mg ÷ 5 mL = 15 mg/mL.

Step 2 is to calculate the volume of oral suspension needed to deliver 225 mg of clindamycin palmitate. This is done by dividing the desired dose by the amount of clindamycin palmitate per mL. So, 225 mg ÷ 15 mg/mL = 15 mL.

Therefore, the nurse should administer 15 mL of clindamycin palmitate oral suspension.

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A nurse is attending to a client who has suffered a basal skull fracture. During the morning hygiene care, the nurse observes a thin clear drainage coming from the client’s right nostril. What should be the nurse’s immediate action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When caring for a patient with burns, which assessment data will alert the nurse to the possibility of a local infection of the burned area?

Correct Answer is C

Explanation

A nurse is preparing to administer clindamycin palmitate 225 mg PO to a client. Available is clindamycin palmitate oral suspension 75 mg/5 mL. How many ml’s should the nurse administer?

Correct Answer is ["15"]

Explanation

A nurse is educating a patient newly diagnosed with iron deficiency anemia. Which of the following would be a component of the education?

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A nurse is attending to a client who has suffered a basal skull fracture.

During the morning hygiene care, the nurse observes a thin clear drainage coming from the client’s right nostril.

What should be the nurse’s immediate action?