The emergency room nurse is assessing a newly admitted patient with a head injury.The nurse observes clear drainage from the nose.Which action should the nurse perform first?

Question

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Head injury symptoms may include rhinorrhea (fluid from the nose)or otorrhea (fluid from the ear),among many others.Rhinorrhea and otorrhea should be tested to determine if there is a cerebrospinal fluid (CSF)leak.Testing with a Dextrostix will determine whether glucose is present; the presence of glucose indicates CSF.Documentation,informing the physician,and applying a drip pad under the nose are actions that should occur after confirmation of the fluid type.

The Emergency Room Nurse Is Assessing a Newly Admitted Patient