QUESTION: 59

A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to:

Pass a nasogastric tube through the left nostril
Place a 4 X 4 gauze in the nares to impede the flow
Gently suction the nasal drainage to protect the airway
Perform a halo test and glucose level on the drainage

Answer(s): D

Explanation:

(A) Basilar skull fracture may cause dural lacerations, which result in CSF leaking from the ears or nose. Insertion of a tube could lead to CSF going into the brain tissue or sinuses. (B) Tamponading flow could worsen the problem and increase ICP. (C) Suction could increase brain damage and dislocate tissue. (D) Testing the fluid from the nares would determine the presence of CSF. Elevation of the head, notification of the medical staff, and prophylactic antibiotics are appropriate therapy.

Reveal Solution Next Question

QUESTION: 59

A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to:

Pass a nasogastric tube through the left nostril
Place a 4 X 4 gauze in the nares to impede the flow
Gently suction the nasal drainage to protect the airway
Perform a halo test and glucose level on the drainage

Answer(s): D

Explanation:

(A) Basilar skull fracture may cause dural lacerations, which result in CSF leaking from the ears or nose. Insertion of a tube could lead to CSF going into the brain tissue or sinuses. (B) Tamponading flow could worsen the problem and increase ICP. (C) Suction could increase brain damage and dislocate tissue. (D) Testing the fluid from the nares would determine the presence of CSF. Elevation of the head, notification of the medical staff, and prophylactic antibiotics are appropriate therapy.

Reveal Solution Next Question

QUESTION: 60

A pregnant woman at 36 weeks' gestation is followed for PIH and develops proteinuria. To increase protein in her diet, which of the following foods will provide the greatest amount of protein when added to her intake of 100 mL of milk?

Fifty milliliters light cream and 2 tbsp corn syrup
Thirty grams powdered skim milk and 1 egg
One small scoop (90 g) vanilla ice cream and 1 tbsp chocolate syrup
One package vitamin-fortified gelatin drink

Answer(s): B

Explanation:

(A) This choice would provide more unwanted fat and sugar than protein. (B) Skim milk would add protein. Eggs are good sources of protein while low in fat and calories. (C) The benefit of protein from ice cream would be outweighed by the fat content. Chocolate syrup has caffeine, which is contraindicated or limited in pregnancy. (D) Although most animal proteins are higher in protein than plant proteins, gelatin is not. It loses protein during the processing for food consumption.

Reveal Solution Next Question

QUESTION: 60

A pregnant woman at 36 weeks' gestation is followed for PIH and develops proteinuria. To increase protein in her diet, which of the following foods will provide the greatest amount of protein when added to her intake of 100 mL of milk?

Fifty milliliters light cream and 2 tbsp corn syrup
Thirty grams powdered skim milk and 1 egg
One small scoop (90 g) vanilla ice cream and 1 tbsp chocolate syrup
One package vitamin-fortified gelatin drink

Answer(s): B

Explanation:

(A) This choice would provide more unwanted fat and sugar than protein. (B) Skim milk would add protein. Eggs are good sources of protein while low in fat and calories. (C) The benefit of protein from ice cream would be outweighed by the fat content. Chocolate syrup has caffeine, which is contraindicated or limited in pregnancy. (D) Although most animal proteins are higher in protein than plant proteins, gelatin is not. It loses protein during the processing for food consumption.

Reveal Solution Next Question

Free NCLEX-RN Exam Braindumps (page: 31)

QUESTION: 59

Explanation:

QUESTION: 59

Explanation:

QUESTION: 60

Explanation:

QUESTION: 60

Explanation:

NCLEX-RN Discussions & Posts