The nurse notes that a patient with a head injury has clear nasal drainage. The most appropriate nursing action is to:

The nurse notes that a patient with a head injury has clear nasal drainage. The most appropriate nursing action is to:

• A. Obtain a specimen of the fluid and send for culture and sensitivity.
• B. Take the patient's temperature to determine whether a fever is present.
• C. Check the nasal drainage for glucose with a Dextrostik or Testape.
• D. Have the patient blow the nose and then check the nares for redness

Answer: (C)

The key idea is recognizing a suspected CSF leak after head injury and confirming it at the bedside. Clear nasal drainage with a head injury raises concern for CSF leakage from a basilar skull fracture. CSF contains glucose, so testing the nasal drainage with a Dextrostik or Testape helps distinguish CSF from ordinary nasal mucus. If the test is positive for glucose, it supports a CSF leak and should be reported promptly to the physician so appropriate precautions and imaging can be started to prevent meningitis. Cuffing culture or sensitivity isn’t the immediate step because it doesn’t confirm the leak and can delay urgent management. Checking for fever doesn’t establish whether drainage is CSF. Asking the patient to blow the nose isn’t helpful and could worsen or spread the leak.

The key idea is recognizing a suspected CSF leak after head injury and confirming it at the bedside. Clear nasal drainage with a head injury raises concern for CSF leakage from a basilar skull fracture. CSF contains glucose, so testing the nasal drainage with a Dextrostik or Testape helps distinguish CSF from ordinary nasal mucus. If the test is positive for glucose, it supports a CSF leak and should be reported promptly to the physician so appropriate precautions and imaging can be started to prevent meningitis.

Cuffing culture or sensitivity isn’t the immediate step because it doesn’t confirm the leak and can delay urgent management. Checking for fever doesn’t establish whether drainage is CSF. Asking the patient to blow the nose isn’t helpful and could worsen or spread the leak.