Ati nur211 mobility exam
Ati nur211 mobility exam ( 29 Questions)
A nurse is assessing a client with a basal skull fracture and observes a thin stream of clear fluid coming from the client's right nostril. What should the nurse's initial action be?
Suctioning the nose is not the first action to take. Suctioning can increase intracranial pressure and potentially cause further injury. It is important to first determine the nature of the drainage before taking any invasive actions.
Notifying the physician is important, but it should be done after confirming the nature of the drainage. Testing the fluid for glucose can help determine if it is cerebrospinal fluid (CSF), which would indicate a serious complication requiring immediate medical attention.
Testing the drainage for glucose is the correct first action. CSF contains glucose, so a positive test would confirm that the clear fluid is CSF. This is a critical step in diagnosing a CSF leak, which can occur with basal skull fractures and requires prompt intervention to prevent infection and other complications.
Asking the client to blow their nose is contraindicated. Blowing the nose can increase intracranial pressure and exacerbate a CSF leak. It is important to avoid any actions that could worsen the condition until the nature of the drainage is confirmed.
Choice A Reason:
Suctioning the nose is not the first action to take. Suctioning can increase intracranial pressure and potentially cause further injury. It is important to first determine the nature of the drainage before taking any invasive actions.
Choice B Reason:
Notifying the physician is important, but it should be done after confirming the nature of the drainage. Testing the fluid for glucose can help determine if it is cerebrospinal fluid (CSF), which would indicate a serious complication requiring immediate medical attention.
Choice C Reason:
Testing the drainage for glucose is the correct first action. CSF contains glucose, so a positive test would confirm that the clear fluid is CSF. This is a critical step in diagnosing a CSF leak, which can occur with basal skull fractures and requires prompt intervention to prevent infection and other complications.
Choice D Reason:
Asking the client to blow their nose is contraindicated. Blowing the nose can increase intracranial pressure and exacerbate a CSF leak. It is important to avoid any actions that could worsen the condition until the nature of the drainage is confirmed.