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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A) Ventilator-associated pneumonia (VAP):
Ventilator-associated pneumonia (VAP) is a type of pneumonia that develops in patients who have been on mechanical ventilation for more than 48 hours. It is a common and serious complication in critically ill patients on ventilators. Symptoms such as fever, green sputum, and right lower lobe crackles are indicative of a respiratory infection, which, in this case, is most likely VAP. VAP typically presents with signs of infection such as elevated temperature, purulent sputum, and new infiltrates on a chest x-ray, in addition to lung crackles.

B) Pulmonary embolism (PE):
Although pulmonary embolism (PE) can cause symptoms like tachypnea, chest pain, and dyspnea, it does not typically cause a fever, green sputum, or localized crackles in the lungs. PE is usually characterized by sudden onset of respiratory distress, often accompanied by hemoptysis or chest pain, and would not typically present with the localized findings in the lower lobe (e.g., crackles).

C) Stress ulcer:
Stress ulcers can occur in critically ill patients, especially those on mechanical ventilation, due to the stress response and reduced blood flow to the stomach. However, stress ulcers typically cause gastrointestinal symptoms, such as melena (black, tarry stools) or hematemesis (vomiting blood).

D) Pneumothorax:
A pneumothorax occurs when air accumulates in the pleural space, causing a collapse of the lung. It can lead to symptoms such as sudden chest pain, dyspnea, and diminished breath sounds on one side of the chest. However, it would not typically cause fever, green sputum, or localized crackles.

A. CD4 count of less than 200 cells/uL, (ranges 500-1800) and new diagnosis of pneumocystis pneumonia B. CD4 count of 1200 cells/uL (ranges 500-1800) and a new diagnosis hepatitis A C. low grade fever with the diagnosis of influenza A D. New atopic dermatitis and a White Blood count 11 million/mm3

Correct Answer is A

Explanation

A) CD4 count of less than 200 cells/uL, and new diagnosis of pneumocystis pneumonia:
A CD4 count of less than 200 cells/uL and the diagnosis of a severe opportunistic infection, such as pneumocystis pneumonia (PCP), are major criteria for the diagnosis of acquired immunodeficiency syndrome (AIDS). AIDS is the final stage of HIV infection, where the immune system is severely compromised, and the individual is highly susceptible to opportunistic infections like PCP, tuberculosis, and others. The CD4 count, which measures the number of immune system cells (specifically T-helper cells), is used to monitor disease progression, with values below 200 cells/uL indicating a diagnosis of AIDS.

B) CD4 count of 1200 cells/uL and a new diagnosis of hepatitis A:
While hepatitis A is an important condition that should be managed, it is not an opportunistic infection associated with AIDS. A CD4 count of 1200 cells/uL is within the normal range (500-1800 cells/uL), indicating that the immune system is not severely compromised.

C) Low grade fever with the diagnosis of influenza A:
A low-grade fever and a diagnosis of influenza A do not indicate AIDS. Influenza is a viral infection that can affect both individuals with and without HIV. It is common to experience flu-like symptoms in the early stages of HIV infection, but the presence of a fever and influenza does not confirm AIDS. A low-grade fever is also not specific to AIDS or opportunistic infections.

D) New atopic dermatitis and a white blood count of 11 million/mm³:
Atopic dermatitis is a chronic inflammatory skin condition that is not specifically associated with HIV or AIDS. The white blood cell (WBC) count of 11 million/mm³ is elevated, but this alone does not confirm a diagnosis of AIDS. Elevated WBC counts can occur with various conditions, including infections and allergic reactions, but they are not a diagnostic feature of AIDS.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has been on a mechanical ventilator for three days develops a fever of 101 degrees Fahrenheit green sputum, and right lower lobe crackles. The nurse contacts the physician regarding possible development of which complication?

Correct Answer is A

Explanation

The nurse is providing care for a client who has tested positive for human immunodeficiency virus (HIV). Which of the following findings would confirm the diagnosis of acquired immunodeficiency syndrome (AIDS) in this client?

Correct Answer is A

Explanation

A patient presents to the Emergency Department (ED) reporting right facial weakness. The nurse understands that a patient suffering from Bell's Palsy will exhibit which assessment findings related to the cranial nerve involvement?

In educating clients about ovarian cancer the nurse emphasizes death rates for ovarian cancer are high because:

The nurse is monitoring a patient receiving a blood transfusion. For Which symptoms would the nurse stop the transfusion but NOT administer 0,9% normal saline?

When using an ECG rhythm strip to quickly estimate the ventricular rhythm for a client, the nurse should:

The nurse is caring for client who is diagnosed with hypertrophic cardiomyopathy. Which medical Intervention should the nurse anticipate for this client for the complications of dysrhythmias?

The nurse understands the primary assessment for a patient following a major trauma:

The nurse is reviewing lab results for a client receiving chemotherapy for the treatment of cancer. The nurse notes the carcinoembryonic antigen (CEA) was previously 50 ng/ mL and is now 10 ng/mL (normal range 0-2.5 ng/mL) The nurse is aware this finding indicates the:

The nurse is caring for a client with infectious endocarditis. Which information obtained from the health history could have contributed to the development of the disease progress?