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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10","472"]
Explanation
Both legs account for approximately 36% of total body surface area (18% per leg × 2).
Convert weight to kilograms: 160 lbs ÷ 2.2 = 72.73 kg
Using the Parkland formula:
4 mL × 72.73 kg × 36 = 10,472 mL of fluid for the first 24 hours
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.
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