The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.
The nurse notices a yellow stain around fluid dripping from the patient's ear.
The nurse's priority intervention will be as follows:
Prevent the drainage by applying a pressure dressing.
Allow fluid to drain from the patient's ear onto gauze and notify the provider.
Hang intravenous (IV) fluids to replace fluids lost.
Administer antibiotics due to increased risk of infection.
The Correct Answer is B
Choice A rationale
Applying pressure to prevent drainage could force cerebrospinal fluid (CSF) back into the cranial cavity, increasing infection risk and intracranial pressure, potentially worsening brain injury. CSF leakage requires non-obstructive handling.
Choice B rationale
Allowing fluid to drain onto gauze prevents build-up of intracranial pressure while assessing for halo sign, indicating CSF leakage. Yellow staining reflects glucose presence in CSF, confirming dura mater damage.
Choice C rationale
Intravenous fluids manage hypovolemia but are not prioritized for trauma patient brain injuries. Replacing lost CSF requires specific medical intervention rather than fluid volume adjustments alone.
Choice D rationale
Antibiotics treat infections but are not first priority for confirmed CSF leakage, which demands careful monitoring of drainage to prevent neurological damage. Post-intervention antibiotics may be necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Applying pressure to prevent drainage could force cerebrospinal fluid (CSF) back into the cranial cavity, increasing infection risk and intracranial pressure, potentially worsening brain injury. CSF leakage requires non-obstructive handling.
Choice B rationale
Allowing fluid to drain onto gauze prevents build-up of intracranial pressure while assessing for halo sign, indicating CSF leakage. Yellow staining reflects glucose presence in CSF, confirming dura mater damage.
Choice C rationale
Intravenous fluids manage hypovolemia but are not prioritized for trauma patient brain injuries. Replacing lost CSF requires specific medical intervention rather than fluid volume adjustments alone.
Choice D rationale
Antibiotics treat infections but are not first priority for confirmed CSF leakage, which demands careful monitoring of drainage to prevent neurological damage. Post-intervention antibiotics may be necessary.
Correct Answer is ["0.1"]
Explanation
Step 1 is (225 mcg ÷ 1000 mcg) × 0.50 tablets.
Answer is 0.1 tablets.
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