Difficulty: Medium
Average Score: 77%
Simulated
What should the nurse do first when a client with a head injury begins to have clear drainage from his nose?
Correct answer
C
Rationale
Clear drainage from the nose after a head injury may indicate cerebrospinal fluid (CSF) leakage, a serious condition. The priority is to collect the fluid for analysis to confirm CSF and avoid infection, making providing tissues the first action. Compressing the nares or tilting the head back could increase intracranial pressure or contaminate the fluid, and an antihistamine is inappropriate without confirming the cause.