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","C"]

Explanation

A. Temperature 37.2°C and HR 88/min are within normal limits; not indicative of sepsis.

B. Tachycardia and tachypnea are common signs of sepsis.

C. Altered mental status and tachycardia are potential manifestations of sepsis.

D. Bradypnea is not typical of sepsis; WBC is normal.

E. Temperature 36°C and RR 16/min are normal; not indicative of sepsis.

A. Initiate fluid resuscitation. B. Insert an indwelling urinary catheter. C. Medicate for pain. D. Maintain the airway.

Correct Answer is D

Explanation

A. Initiating fluid resuscitation is a vital component of burn management during the resuscitation phase, but it follows airway stabilization in priority.
B. Inserting an indwelling urinary catheter is important for monitoring fluid output and kidney function, but it is not the immediate priority.
C. Pain management is essential in burn care, but it is not the most urgent intervention during the initial phase of care.
D. According to the ABCs of emergency care (Airway, Breathing, Circulation), securing the airway is always the first priority, especially in clients with burns to the chest and upper body where airway edema and inhalation injury are likely.

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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 is caring for a group of critically ill clients. Which of the following clients are exhibiting potential manifestations of sepsis? (Select All that Apply.)

Correct Answer is ["B","C"]

Explanation

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury?

Correct Answer is D

Explanation

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