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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A cold, pulseless foot indicates compromised blood flow, a medical emergency following an arteriogram. The nurse should immediately notify the physician to address potential vascular occlusion.
B. Elevating the limb can further impair circulation if blood flow is already compromised.
C. Covering the limb will not address the underlying issue of impaired circulation.
D. Repositioning may delay timely intervention in what may be a vascular emergency.
Correct Answer is C
Explanation
A. This is a correct statement, as using multiple drugs helps to reduce the likelihood of resistance and enhances viral suppression.
B. This is accurate; if resistance develops, alternative medications or combinations can be considered.
C. This statement indicates a misunderstanding. Antiretroviral medications do not kill the virus; they suppress its replication. Lifelong adherence to antiretroviral therapy is necessary to manage HIV and prevent viral rebound.
D. Correct, as an effective regimen should lead to an increase in CD4 count and improved immune function.
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