— 生理適應 · MEDIUM · MCQ —
一位頭部外傷病人鼻部流出清澈液體，優先護理措施為何？
A client with a head injury exhibits clear fluid draining from the nose. What is the priority nursing action?
- ATest the fluid for glucose✓ 正解測試液體的葡萄糖含量
- BPack the nose with sterile gauze用無菌紗布填塞鼻子
- CSuction the nasal cavity抽吸鼻腔
- DAsk the client to blow their nose gently請病人輕輕擤鼻子
— Explanation · 中文詳解 —
頭部外傷後的鼻溢液需懷疑腦脊髓液（CSF）外漏。測試液體是否有葡萄糖（大於 30 mg/dL）可判斷是否為 CSF。禁止填塞或抽吸，以防感染入腦。不可讓病人擤鼻涕，以免增加 intracranial pressure 導致外漏加劇。
Clear fluid draining from the nose after a head injury may indicate cerebrospinal fluid (CSF) leakage, which is tested for glucose. Nurses must avoid packing the nose, suctioning, or having the client blow their nose, as these actions increase the risk of intracranial infection and pressure.
✦ 台美臨床差異
美國強調神經外科會診及 bedside testing；台灣常直接安排影像學檢查（CT/MRI）確認顱底骨折。