The nurse notes that a patient with a head injury has a clear nasal drainage. The most appropriate nursing action for this finding is to

Question

Quizplus · Accepted Answer

If the drainage is cerebrospinal fluid (CSF) leakage from a dural tear, glucose will be present. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. A dural tear does increase the risk for infections such as meningitis, but the nurse should first determine whether the clear drainage is CSF. Blowing the nose is avoided to prevent CSF leakage.

The Nurse Notes That a Patient with a Head Injury