The client has been brought via ambulance to the emergency room following a motor vehicle accident. The nurse notes that the client's ear is draining clear fluid. What is the nurse's priority nursing action?

Question

1. Request information from the client regarding any chronic allergies.
2. Test the drainage for glucose.
3. Ask the patient if she has experienced a recent middle ear infection.
4. Irrigate the ear with warm mineral oil, peroxide, and flush with warm water.

Answer 1

2
Rationale 1: Chronic allergies would not result in clear fluid draining from the client's ear. However, an acute allergic reaction may result in serous fluid that drains from the client's ear.
Rationale 2: When a client's ear is draining clear fluid, this might indicate the client has a cerebrospinal fluid leak. The fluid should be tested for glucose. Glucose is present in cerebrospinal fluid.
Rationale 3: A recent middle ear infection may result in purulent or bloody drainage from the client's ear.
Rationale 4: The ear should not be irrigated at this time. Irrigation with warm mineral oil, peroxide, and flushing with warm water is often used to remove cerumen. There is nothing to suggest that the client has impacted cerumen.