The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder.Upon admission,the nurse assesses the patient to be awake,alert,and moving all four extremities.The nurse also notes bruising behind the left ear and straw-colored drainage from the left nare.What is the most appropriate nursing action?
A) Insert bilateral ear plugs.
B) Monitor airway patency.
C) Maintain neutral head position.
D) Apply a small nasal drip pad.

Question

Quizplus · Accepted Answer

Patient assessment findings are indicative of a skull fracture.The presence of straw-colored nasal draining may be indicative of a CSF leak.Drainage should be monitored and allowed to flow freely.Application of a nasal drip pad is the most appropriate action.Monitoring airway patency and maintaining the head in a neutral position are not priorities in a patient who is awake and alert.Insertion of bilateral ear plugs is not standard of care.

The Nurse Is Caring for a Patient Admitted to the ED