A nurse is caring for a pediatric patient who had a basilar skull fracture. The nurse assessed that there is a clear fluid leaking from the ears of the child. The nurse concludes that it is cerebrospinal fluid if the fluid:
  1. Is grossly bloody in appearance and has a pH level of 6.1
  2. Clumps together on the dressing and has a pH level of 7
  3. Separates into concentric rings and tests positive for glucose
  4. Is clear and tests negative for glucose
Explanation
Answer - C - The nurse concludes that it is a cerebrospinal fluid if the fluid separates into concentric rings and tests positive for glucose. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a “halo sign.” The fluid also tests positive for glucose.
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