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…

The correct answer is D. Perform a halo test and glucose level on the drainage. (A) Basilar skull fracture may cause dural lacerations, which result in CSF leaking from the ears or nose. Insertion of a tube could lead to CSF going into the brain tissue or sinuses. (B) Tamponading flow could worsen the problem and increase ICP. (C) Suction could increase…

Physiological Integrity: Reduction of Risk Potential

Question

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:

Options

APass a nasogastric tube through the left nostril
BPlace a 4 X 4 gauze in the nares to impede the flow
CGently suction the nasal drainage to protect the airway
DPerform a halo test and glucose level on the drainage

How the community answered

(16 responses)

A
19% (3)
B
6% (1)
C
6% (1)
D
69% (11)

Explanation

(A) Basilar skull fracture may cause dural lacerations, which result in CSF leaking from the ears or nose. Insertion of a tube could lead to CSF going into the brain tissue or sinuses. (B) Tamponading flow could worsen the problem and increase ICP. (C) Suction could increase brain damage and dislocate tissue. (D) Testing the fluid from the nares would determine the presence of CSF. Elevation of the head, notification of the medical staff, and prophylactic antibiotics are appropriate therapy.

Topics

#basilar skull fracture#CSF rhinorrhea#halo test#head injury assessment

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