Nokea
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?
- A. Test the drainage for the halo sign.
- B. Ask the client to blow his nose.
- C. Notify the physician.
- D. Suction the nostril.
Correct Answer: A
Rationale: Testing for the halo sign (glucose in drainage) helps identify CSF leakage which requires immediate intervention.
You may also like to solve these questions
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?
- A. Sodium level
- B. Intake and output
- C. Daily weight
- D. Tissue turgor
Correct Answer: C
Rationale: Daily weight is the most reliable measure of fluid retention as 1 kg weight gain equals approximately 1 liter fluid retention.
A nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis due to the risk of which complication?
- A. Hyperglycemia
- B. Disequilibrium syndrome
- C. Peritonitis
- D. Hyperphosphatemia
- E. The client experiences pain upon palpation of the epigastric region.
Correct Answer: A
Rationale: Maintaining dwell time prevents excessive glucose absorption from dialysate which could cause hyperglycemia.
The nurse is caring for a client who has a small bowel obstruction. When teaching the student nurse about this condition, the nurse will include which of the following findings that are consistent with the diagnosis? (Select all that apply).
- A. Severe fluid and electrolyte imbalance
- B. Upper abdominal distention
- C. Metabolic acidosis
- D. Projectile vomiting with a fecal odor
- E. Diarrhea or ribbon-like stools
Correct Answer: A,B,D
Rationale: These reflect SBO pathophysiology: proximal distention, fluid loss/vomiting, and metabolic derangements.
A client is admitted to the emergency department after sustaining multiple rib fractures in a motor vehicle accident. Upon assessment, the nurse notes that the client has flail chest. Which of the following signs and symptoms are associated with this condition? (Select all that apply.)
- A. Bradycardia
- B. Anxiety
- C. Dyspnea
- D. Unequal chest expansion
- E. Hypotension
- F. Paradoxical chest movement
Correct Answer: B,C,D,E,F
Rationale: Flail chest causes respiratory distress, paradoxical movement, and can lead to shock.
A nurse is assessing clients in a health clinic for risk factors for contracting hepatitis. Which of the following clients is at risk for developing hepatitis C?
- A. A client who works in a child care center
- B. A client who eats raw shellfish
- C. A client who has multiple tattoos
- D. A client who has recently traveled to an underdeveloped country
Correct Answer: C
Rationale: Tattoos with non-sterile equipment are a risk factor for HCV transmission.