A craniotomy patient has just returned from surgery. The nurse completing the initial assessment notes fluids leaking from the patient's nose
An appropriate initial nursing intervention to complete at this time would include which of the following?
A) Prepare for a lumbar puncture.
B) Test the leaking fluid with a Dextrostix.
C) Document the abnormal find as the only intervention.
D) Pack the patient's nose to prevent leakage.
Ans: B
Feedback: Nursing management of leakage of cerebrospinal fluid (CSF) focuses on differentiating CSF from mucus. The nurse should collect the fluid on a Dextrostix. If CSF is present, the indicator will have a positive reaction, as CSF contains glucose. Refer to Chart 61-2, page 1869. The patient would not be prepared for a lumbar puncture at this time, nor would his nose be packed; this could lead to increased intracranial pressure. A loose dressing may be applied to absorb the drainage initially.
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