The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client’s nostril. The nurse should take which initial action?

Lower the head of the bed. Test the drainage for glucose.Obtain a culture of the drainage.Continue to observe the drainage.

Explanation.

After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and tested for the presence of cerebrospinal fluid. Cerebrospinal fluid contains glucose, and if positive, this would indicate that the drainage is cerebrospinal fluid. The head of the bed should remain elevated to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication.