Practice Quiz

CMSRN Medical-Surgical Nursing

Category - Endocrine

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Following a hypophysectomy, the client complains of clear nasal drainage. What is the most appropriate initial action for the nurse?
  1. Notify the surgeon immediately
  2. Encourage the client to blow his nose to clear the sinuses
  3. Check the nasal drainage for glucose
  4. Place the client in Trendelenburg position
Explanation
Answer - C - Check the nasal drainage for glucose. A cerebral spinal leak is suspected and testing the fluid for the presence of glucose would confirm this. Most leaks heal spontaneously, but occasionally, surgical repair is needed. Packing the nose will not heal the leak at this site. The head of the bed should not be elevated to decrease pressure on the graph site and blowing the nose is contraindicated.
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