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.
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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Related Questions
Correct Answer is A
Explanation
Choice A rationale
Severe upper abdominal pain can be a sign of gastrointestinal perforation in a patient with peptic ulcer disease. When an ulcer erodes through the wall of the stomach or duodenum, it can cause a perforation, or hole. This is a serious complication that can cause severe pain.
Correct Answer is B
Explanation
Choice A rationale
Gastroesophageal reflux disease (GERD) is a chronic condition where stomach acid frequently flows back into the esophagus, irritating the lining and causing symptoms like heartburn. Protonix (pantoprazole) is a proton pump inhibitor that decreases the amount of acid produced in the stomach. While it is used to treat GERD, it is not typically used prophylactically in trauma patients.
Choice B rationale
Stress ulcers are a type of peptic ulcer that is particularly common in critically ill or severely stressed patients, such as those with severe trauma like an automobile accident. These ulcers occur when the body’s physical stress leads to increased gastric acid secretion, which can damage the gastric mucosa and lead to ulcers. Protonix, by reducing stomach acid, can help prevent these ulcers in high-risk patients. This is why it is often administered prophylactically in severe trauma cases.
Choice C rationale
Dumping syndrome is a condition that can occur after surgery to remove all or part of your stomach or after surgery to bypass your stomach to help you lose weight. It’s also known as rapid gastric emptying. Protonix is not typically used to prevent dumping syndrome.
Choice D rationale
Gastritis is an inflammation of the stomach lining. While Protonix can be used to treat gastritis, it is not typically used prophylactically for this condition in trauma patients.
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