The emergency room nurse is assessing a newly admitted patient with a head injury. The nurse observes clear drainage from the nose. Which action should the nurse perform first?
a. Document the presence of rhinorrhea.
b. Inform the physician of the assessment.
c. Test the fluid with a Dextrostix.
d. Tape a drip pad under the nose.
C
Head injury symptoms may include rhinorrhea (fluid from the nose) or otorrhea (fluid from the ear), among many others. Rhinorrhea and otorrhea should be tested to determine if there is a ce-rebrospinal fluid (CSF) leak. Testing with a Dextrostix will determine whether glucose is present; the presence of glucose indicates CSF. Documentation, informing the physician, and applying a drip pad under the nose are actions that should occur after confirmation of the fluid type.
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