The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question?
a. Keep the head of bed elevated.
b. Insert nasogastric tube to low suction.
c. Turn patient side to side every 2 hours
d. Apply cold packs intermittently to face.
ANS: B
Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage. Insertion of a naso-gastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.
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