The client has been brought via ambulance to the emergency department (ED) following a motor vehicle accident. The nurse notes that the client's ear is draining clear fluid. Which is the priority nursing action?
1. Requesting information from the client regarding any chronic allergies.
2. Testing the drainage for glucose.
3. Asking the client if there have been recent middle ear infections.
4. Irrigating the ear with warm mineral oil or peroxide, and flushing with warm water.
Correct Answer: 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. 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. A recent middle ear infection may result in purulent or bloody drainage from the client's ear. 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.
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