Practice Quiz

NCLEX-RN

Category - Reduction of Risk

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A nurse in the emergency room assesses a client with a head injury. During assessment, fluid is noted to be leaking from the client’s nose is noted. The nurse determines it is the cerebrospinal fluid if which of the following is observed?
  1. Clumping is noted on the dressing, positive for glucose
  2. Bloody, negative for glucose
  3. Blood and yellow concentric rings form on the dressing, positive for glucose
  4. Clear, negative for glucose
Explanation
Answer - C - The cerebrospinal fluid separates into bloody and yellow concentric rings on the dressing. Cerebrospinal fluid leaking from the client’s nose or ears is a sign of basilar skull fracture. The CSF is also positive for glucose.
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