A nurse is caring for a client who is 24 hours postoperative after a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action?

No further intervention required.

Remove the nasal packing and dressing.

Perform a Halo test with the drainage.

Encourage client to blow their nose.

Answer and Explanation

The Correct Answer is C

A. Further assessment is needed when clear drainage is noted to rule out cerebrospinal fluid (CSF) leak.
B. Removing nasal packing can increase the risk of bleeding and should not be done without a provider’s order.
C. Performing a Halo test helps identify if the drainage contains CSF, which indicates a possible leak and requires immediate attention.
D. Encouraging the client to blow their nose could increase intracranial pressure and worsen the leak.

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Correct Answer is B

Explanation

A. Active bleeding is important but airway and breathing take precedence.
B. Altered respirations indicate airway compromise or respiratory distress, which is the most critical priority to assess and manage first.
C. Facial asymmetry is a sign of injury but less urgent than airway or breathing problems.
D. Soft-tissue edema can impair breathing but is secondary to immediate respiratory assessment.

A. Pacemaker B. Alcohol use disorder C. Breast cancer survivor for 8 years D. 65-years of age

Correct Answer is B

Explanation

A. Having a pacemaker is not an absolute contraindication for kidney transplant, though it requires careful evaluation.
B. Active substance abuse, including alcohol use disorder, is generally considered a contraindication for kidney transplantation due to concerns about adherence to medical regimens and potential for complications.
C. Being a breast cancer survivor for 8 years is usually not a contraindication if the client has been cancer-free for a significant period and is deemed stable.
D. Age 65 years is not an absolute contraindication; many older adults can be candidates for transplant based on overall health status rather than age alone.

View Question and Answer

A nurse is caring for a client who is admitted to the emergency department for fatigue.

Exhibits

Which 4 findings indicate that the client may be experiencing transplant rejection? (Select all that apply).

View Question and Answer

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A nurse is caring for a client who is 24 hours postoperative after a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is assessing a newly admitted client who has facial trauma. Which of the following assessments is the nurse's priority?

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Explanation

A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment?

Correct Answer is B

Explanation

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A nurse is caring for a client who is admitted to the emergency department for fatigue. Exhibits Which 4 findings indicate that the client may be experiencing transplant rejection? (Select all that apply).

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