A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to:
A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to:
When a patient with a basilar skull fracture exhibits blood-tinged drainage from the nose, it is crucial to determine whether the fluid is cerebrospinal fluid (CSF). A basilar skull fracture can lead to dural tears, causing CSF to leak from the nose or ears. Performing a halo test and checking the glucose level on the drainage helps confirm the presence of CSF. This information is vital for the appropriate management of the patient. Steps such as passing a nasogastric tube, placing gauzes in the nares, or suctioning could worsen the condition by introducing infection or increasing intracranial pressure (ICP), or causing further damage.
Answer D