Ati ew n300 med surg final proctored exam
The nurse notices a yellow stain around fluid dripping from a patient's ear who sustained a traumatic brain injury. The nurse's priority intervention will be as follows:
Explanation & Rationale
A. Hanging IV fluids is important for hydration but is not the immediate priority when fluid is draining from the ear. B. Applying a tight pressure dressing may increase intracranial pressure and is contraindicated in cases of possible cerebrospinal fluid (CSF) leakage. C. Administering antibiotics may be necessary later but only after assessment and provider orders; it is not the initial priority. D. Allowing fluid to drain onto gauze prevents pressure buildup, helps monitor the drainage (which may be CSF), and notifying the provider is essential for further evaluation and treatment.
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