The nurse is caring for a patient after a hypophysectomy. The nurse notices clear nasal drainage from the patient's nostril. The first nursing action would be to...which of these....
1. Continue to observe the drainage.
2. Test the drainage for glucose
3.lower the head of the bed
4. Obtain a culture of the drainage
From: Comprehensive review for the NCLEX-RN examination, (Saunders)p.664
answer= 2 test the drainage for glucose.
ReplyDeletelooking for CSF leak. Do not lower the head of the bed. Bed should be up to prevent intracranial pressure.
(Saunders)p 644
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