The nurse is assessing a client who is 6 hours post surgery for a nasal fracture. The client has facial pain (5 out of 10) and nasal packing in place. What actions by the nurse are most appropri-ate at this time? (Select all that apply.)

Question

a. Observe for clear drainage.
b. Observe for bleeding.
c. Observe the client for frequent swallow-ing.
d. Ask the client to open his or her mouth.
e. Administer a nasal steroid to decrease edema.
f. Change the nasal packing.
g. Administer pain medication.
h. Place the client in Trendelenburg position.

Answer 1

A, B, C, D, G
The nurse should observe for clear drainage because of the risk for cerebrospinal fluid (CSF) leakage. The nurse should note whether the client is swallowing frequently because this could indicate postnasal bleeding. The nurse should also ask the client to open his or her mouth and should observe the back of the throat for bleeding. Pain medication should also be administered. It is too soon to change the packing, which should be changed by the surgeon the first time. A nasal steroid would increase the risk for infection.