What is the most appropriate action by the nurse when clear fluid is leaking from a client's nose after a motor vehicle accident?

• A. Instruct the client to apply firm pressure to the nose.
• B. Obtain a specimen of the fluid for culture and sensitivity.
• C. Obtain a specimen of the fluid for presence of glucose.
• D. Prepare to administer a broad-spectrum antibiotic.

Answer: (C)

The most appropriate action in this scenario is to obtain a specimen of the fluid for the presence of glucose. Clear fluid leaking from the nose after a head injury raises concerns about the possibility of cerebrospinal fluid (CSF) leakage. One of the diagnostic indicators for CSF is the presence of glucose, as CSF typically contains higher glucose levels compared to other body fluids. Testing the fluid for glucose can help confirm whether it is CSF or nasal discharge, guiding further treatment and intervention.

The rationale for not prioritizing the other actions includes considerations like potentially unnecessary interventions or delays in the appropriate identification of the fluid's origin. For example, applying firm pressure to the nose could actually increase pressure within the cranial cavity if CSF is leaking, which is not advisable. Collecting specimens for culture and sensitivity may not be immediately necessary unless there is a clinical suspicion of infection, and delays in diagnosing CSF leakage could result in complications. Administering broad-spectrum antibiotics typically would come after an infection is suspected or confirmed; it’s essential first to determine the nature of the fluid being leaked to inform appropriate treatment.