A nurse in an emergency department is assessing a client who has a basilar skull fracture and serosanguineous nasal discharge following a motor vehicle crash. Which of the following findings should the nurse identify as reliable for determining that the discharge is cerebrospinal fluid?

Choice A rationale:
Placing the client in a low Fowler's position with the knees bent (Choice A) can help reduce tension on the abdominal incision, but it is not the priority when evisceration is present. The focus should be on immediate intervention and preparation for surgery.
Choice B rationale:
Covering the client's wound with a sterile saline-soaked dressing (Choice B) is essential to prevent further contamination and maintain moisture in the exposed tissue. This step helps protect the wound until the client can be taken to the operating room.
Choice C rationale:
Notifying the surgeon about the finding (Choice C) is important, but it should not be done before taking more immediate action. Evisceration requires prompt intervention and transfer to surgery, and the surgeon will be involved once the client is ready for the operation.
Choice D rationale:
Preparing the client for transfer to surgery (Choice D) is the correct sequence of steps in this situation. Evisceration is a surgical emergency that requires immediate intervention to prevent complications and infection. The nurse should stabilize the wound with a sterile dressing and then prepare the client for surgery promptly.

Choice A rationale:
Placing the client on droplet precautions is appropriate for bacterial meningitis, as it is spread through respiratory droplets. This measure helps prevent the spread of infection to others.
Choice B rationale:
The nurse should clarify the prescription to perform a cranial nerve assessment every 2 hours. While cranial nerve assessment is crucial in monitoring neurological status, performing it every 2 hours is excessive and not supported by evidence-based practice. Frequent assessments can be uncomfortable for the client and may not provide additional meaningful information within such a short interval.
Choice C rationale:
Assisting the client out of bed three times per day is essential for promoting mobility and preventing complications such as pressure ulcers and muscle weakness. This prescription is appropriate and does not require clarification.
Choice D rationale:
Assessing the client's weight daily is essential in monitoring fluid balance and nutritional status. There is no need to clarify this prescription, as it is a standard practice in caring for clients with bacterial meningitis.