The client has been brought via ambulance to the emergency department (ED) following a motor vehicle accident. The nurse notes that the client's ear is draining clear fluid. Which is the priority nursing action?

Question

Quizplus · Accepted Answer

Testing the drainage for glucose is the priority nursing action because if the fluid is cerebrospinal fluid (CSF), it will contain glucose. If the test is positive for glucose, it suggests a basilar skull fracture and the client should not be allowed to blow the nose, cough forcefully, or strain. These activities can increase pressure in the brain and lead to neurological deficits. The client should remain quiet until further diagnostics are performed. Options A, C, and D may also be important, but they are not the priority at this time.

The Client Has Been Brought Via Ambulance to the Emergency