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The nurse is caring for a trauma patient with suspected brain injury. The nurse notices a yellow stain around fluid dripping from the patient's ear. The nurse's priority intervention will be as follows:

Administer antibiotics due to increased risk of infection

Prevent the drainage by applying a pressure dressing

Hang intravenous (IV) fluids to replace fluids lost

Allow fluid to drain from the patient's ear onto gauze and notify provider

Answer and Explanation

The Correct Answer is D

A. Antibiotics may be necessary if infection is confirmed, but this is not the priority action.

B. Applying a pressure dressing could increase intracranial pressure or worsen the injury.

C. IV fluids can be helpful in managing shock but are not directly related to CSF leakage management.

D. Yellowish fluid from the ear, which creates a "halo" or yellow ring around it on gauze, may indicate cerebrospinal fluid (CSF) leakage. This is a sign of a potential skull fracture and requires prompt provider notification. Allowing the fluid to drain and collecting it can provide necessary information about the injury.

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Correct Answer is D

Explanation

A. While using a cane or walker may be necessary for some patients experiencing balance issues, it is not a specific instruction related to phenytoin.

B. Phenytoin dosages should not be adjusted solely based on observed seizure activity; the dose must be managed carefully based on serum drug levels and the clinician's guidance.

C. Patients on phenytoin typically require more frequent monitoring of blood levels (every 2-3 months initially) rather than annually, as maintaining therapeutic levels is essential to avoid toxicity or ineffective seizure control.

D. Regular dental visits are crucial for patients taking phenytoin because the medication can cause gingival hyperplasia (overgrowth of gum tissue), which necessitates careful dental hygiene and regular monitoring by a dentist to prevent complications.

A. was touching the client on the shoulder without gloves. B. was recapping a needle before medication administration. C. was not wearing a mask while in the client's room. D. had fluids splashing in their eyes while emptying a bedpan.

Correct Answer is D

Explanation

A. Touching a patient’s shoulder does not pose a risk of HIV transmission, as it is not spread through casual skin contact.

B. While recapping needles is discouraged due to the risk of needlestick injury, it is not an exposure unless an actual needlestick occurs.

C. Not wearing a mask is typically not necessary in all interactions with HIV/AIDS patients unless there is an active infection requiring airborne precautions.

D. Exposure of bodily fluids to mucous membranes (such as the eyes) is a significant occupational exposure risk and should be reported. This requires immediate response and evaluation for potential infection.

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ABG Value	Normal Range
pH	7.35- 7.45
PaCO2	35-45 mm Hg
HCO3	22-25 mEq/L
Base excess	-2 to +2
PaO2	80-95 mm Hg
SaO2	>95%

The nurse is caring for a trauma patient with suspected brain injury. The nurse notices a yellow stain around fluid dripping from the patient's ear. The nurse's priority intervention will be as follows:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who was given a new medical prescription for phenytoin. What would the nurse stress in the discharge instructions regarding this medication?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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