Question

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question?

a. Keep the head of bed elevated.
b. Insert nasogastric tube to low suction.
c. Turn patient side to side every 2 hours
d. Apply cold packs intermittently to face.

Answer 1

The nurse should question the order to insert a nasogastric tube in a patient with a basal skull fracture due to the risk of further injury and potential infection.

Step-by-step explanation:

The nurse should question the admission order to insert a nasogastric tube to low suction in a patient with a basal skull fracture. Inserting a nasogastric tube in a patient with basal skull fracture and cerebrospinal fluid (CSF) leakage (indicated by clear drainage from the nose) could potentially cause further harm or introduce infection to the central nervous system. Moreover, this could worsen the fracture or disrupt the healing process. Keeping the head of the bed elevated is beneficial in these cases, as it reduces intracranial pressure and helps drain the CSF. Turning the patient side to side every 2 hours helps prevent pressure ulcers, and applying cold packs intermittently to the face can help reduce swelling. Therefore, among the admission orders given, the one regarding the nasogastric tube placement stands out as a potential risk.