Nokea
What should the nurse do first when a client with a head injury begins to have clear drainage from his nose?
- A. Compress the nares.
- B. Tilt the head back.
- C. Give the client tissues to collect the fluid.
- D. Administer an antihistamine for postnasal drip.
Correct Answer: C
Rationale: Clear drainage from the nose after a head injury may indicate cerebrospinal fluid (CSF) leakage, a serious condition. The priority is to collect the fluid for analysis to confirm CSF and avoid infection, making providing tissues the first action. Compressing the nares or tilting the head back could increase intracranial pressure or contaminate the fluid, and an antihistamine is inappropriate without confirming the cause.
You may also like to solve these questions
The nurse is conducting a postoperative assessment of a client on the first day after renal surgery. Which of the following findings would be most important for the nurse to report to the physician?
- A. Temperature, 99.8°F (37.7°C).
- B. Urine output, 20 mL/hour.
- C. Absence of bowel sounds.
- D. A 2€ x 2€ area of serosanguineous drainage on the flank dressing.
Correct Answer: B
Rationale: Urine output of 20 mL/hour is critically low, indicating potential renal compromise or obstruction, requiring immediate physician notification.
A client receives fibrinolytic therapy upon admission following a myocardial infarction. He is now receiving an I.V. infusion of heparin sodium at 1,200 units/hour. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive?
Correct Answer: 24 mL/hour
Rationale: To calculate: (1,200 units/hour ÷ 25,000 units) × 500 mL = 24 mL/hour. This is a calculation question, not multiple-choice, so no choices or correct answer letter is provided.
A client has a leg immobilized in traction. Which of the following activities demonstrated by the client indicate that the client understands actions to take to prevent muscle atrophy?
- A. The client adducts the affected leg every 2 hours.
- B. The client rolls the affected leg away from the body's midline twice per day.
- C. The client performs isometric exercises to the affected extremity three times per day.
- D. The client asks the nurse to add a 5-lb weight to the traction for 30 minutes/day.
Correct Answer: C
Rationale: Isometric exercises maintain muscle strength without moving the immobilized leg.
A nurse is helping a suspected choking victim. The nurse should perform the Heimlich maneuver when the victim:
- A. Starts to become cyanotic.
- B. Cannot speak due to airway obstruction.
- C. Can make only minimal vocal noises.
- D. Is coughing vigorously.
Correct Answer: B
Rationale: Inability to speak indicates a complete airway obstruction, necessitating the Heimlich maneuver to dislodge the blockage.
A client with neutropenia is at risk for sepsis. Which of the following is the earliest sign the nurse should monitor for?
- A. Hypotension.
- B. Tachycardia.
- C. Oliguria.
- D. Confusion.
Correct Answer: B
Rationale: Tachycardia is often the earliest sign of sepsis, reflecting the body's response to infection, and requires prompt monitoring in a neutropenic client.