The nurse notices a yellow stain around fluid dripping from a patient’s ear who sustained a traumatic brain injury. The nurse's priority intervention will be as follows:

prevent the drainage by applying a tight pressure dressing

administer antibiotics due to increased risk of infection

allow fluid to drain from the patient's car onto gauze and notify

hang intravenous (IV) fluids to replace fluids lost and prevent dehydration

Answer and Explanation

The Correct Answer is C

A) Prevent the drainage by applying a tight pressure dressing:
Applying a tight pressure dressing is not the appropriate intervention in this case. The presence of fluid draining from the ear, particularly a yellow stain, could indicate cerebrospinal fluid (CSF) leakage, which is a potential sign of a skull fracture or traumatic brain injury (TBI) involving the base of the skull. Applying a tight pressure dressing could potentially increase pressure or cause further injury.

B) Administer antibiotics due to increased risk of infection:
While there is an increased risk of infection with a CSF leak, antibiotics should not be administered immediately unless there is clear evidence of an infection. The priority action is to identify whether the fluid is CSF, as antibiotics alone will not address the underlying issue of a CSF leak. The nurse should allow the fluid to drain, collect a sample, and notify the healthcare provider for further assessment, which may include imaging or testing for the presence of CSF.

C) Allow fluid to drain from the patient's ear onto gauze and notify the healthcare provider:
The yellow stain around the fluid dripping from the patient's ear suggests the possibility of CSF leakage, a sign of a skull base fracture. CSF leakage may occur after a traumatic brain injury and should be handled carefully. The nurse's priority action is to allow the fluid to drain onto gauze to prevent the buildup of pressure and to prevent further leakage into the ear canal. The nurse should also immediately notify the healthcare provider for further evaluation and management.

D) Hang intravenous (IV) fluids to replace fluids lost and prevent dehydration:
While IV fluids may be necessary in some cases for patients with trauma, the priority in this situation is to identify the source and nature of the drainage. If the fluid is CSF, it may be important to manage the leak appropriately rather than focusing solely on replacing fluids. The nurse should first confirm whether the fluid is CSF and notify the healthcare provider for further assessment and management. Replacing fluids may be necessary, but it is not the immediate priority.

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Correct Answer is D

Explanation

A) Respiratory acidosis:
Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO2) in the blood, leading to a decrease in pH. In the given blood gas values, the PaCO2 is 28 mmHg, which is lower than the normal range (35-45 mmHg), indicating that CO2 is being exhaled more than usual, not accumulating.

B) Metabolic acidosis:
Metabolic acidosis results from a decrease in bicarbonate (HCO3-) or an increase in acid in the body. However, in the provided values, the bicarbonate (HCO3-) is normal at 24 mEq/L, and the pH is elevated at 7.51, indicating alkalosis rather than acidosis

C) Metabolic alkalosis:
Metabolic alkalosis occurs when there is an increase in bicarbonate levels or excessive loss of acids, often associated with vomiting or diuretic use. However, in this case, the bicarbonate level (HCO3-) is normal, and the pH is more consistent with alkalosis due to respiratory factors, not metabolic causes.

D) Respiratory alkalosis:
Respiratory alkalosis occurs when there is excessive exhalation of CO2, leading to a rise in blood pH (alkalosis). The pH is 7.51, which is above the normal range (7.35-7.45), indicating alkalosis. Additionally, the PaCO2 is low at 28 mmHg, which suggests that the client is hyperventilating and exhaling too much CO2, confirming respiratory alkalosis as the correct interpretation.

A. be placed in isolation to prevent radiation exposure to others B. avoid consuming any food or fluids for 24 hours prior to the treatment C. avoid all physical activity for six weeks after the treatment D. discontinue all other medications for a week before the treatment

Correct Answer is A

Explanation

A) Be placed in isolation to prevent radiation exposure to others:
Radioactive iodine (I-131) is commonly used to treat thyroid cancer because it targets and destroys thyroid tissue, including any remaining cancerous cells. This treatment involves the administration of a radioactive substance that can be excreted through saliva, urine, and sweat. To minimize radiation exposure to others, patients are often placed in isolation, particularly in a hospital setting, for a period following administration.

B) Avoid consuming any food or fluids for 24 hours prior to the treatment:
While it’s essential for patients to follow specific instructions regarding food and fluid intake, such as avoiding certain foods or fluids that may interfere with absorption or increase the risk of side effects (like dairy products), the patient does not need to avoid all food and fluids for 24 hours after receiving radioactive iodine.

C) Avoid all physical activity for six weeks after the treatment:
While some precautions, such as avoiding close contact with others for a short period of time, may be necessary, avoiding physical activity for six weeks is not usually required. Patients may be advised to take it easy during the initial recovery phase, but they can typically resume normal activities once the initial isolation period is complete and their radiation exposure is below safety thresholds.

D) Discontinue all other medications for a week before treatment:
However, certain medications that affect thyroid function (such as thyroid hormones or antithyroid medications) may need to be adjusted or stopped before treatment to ensure the effectiveness of the radioactive iodine. The specifics would depend on the patient’s condition and the healthcare provider’s instructions.

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The nurse notices a yellow stain around fluid dripping from a patient’s ear who sustained a traumatic brain injury. The nurse's priority intervention will be as follows:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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