A 55-year-old man presents to the health nurse at his workplace with epistaxis. He reports he has had four nosebleeds today, and he is concerned because he can usually control the bleeding himself. What would be the most helpful assessment after the nurse has stopped the bleeding?
Record the amount of blood loss
Ask about the last episode of bleeding and how long it took to stop.
Check the client's vital signs
Inquire if the client had a headache along with the bleeding.
The Correct Answer is C
A. Record the amount of blood loss: While important for documentation, patients often cannot accurately estimate blood loss, especially with nasal bleeding. This step is secondary to assessing the client’s current physiological status following multiple episodes.
B. Ask about the last episode of bleeding and how long it took to stop: This can provide useful information for identifying patterns, but it does not assess the client’s immediate condition or potential complications like hypovolemia or hypertension.
C. Check the client's vital signs: Vital signs offer immediate insight into the client’s circulatory and respiratory status. Multiple episodes of epistaxis in one day could indicate hemodynamic instability or uncontrolled hypertension, making this the priority assessment.
D. Inquire if the client had a headache along with the bleeding: A headache could be associated with elevated blood pressure or sinus involvement, but it is not the most urgent concern after repeated nosebleeds. Assessing vital signs takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. 2–3 days:This is the correct time frame for interpreting a tuberculin skin test (Mantoux test). The induration response should be evaluated 48 to 72 hours after administration to ensure accurate results. Reading the test outside this window may lead to false negatives or unreliable interpretation.
B. 24 hours:Reading the skin test after only 24 hours may not allow sufficient time for the delayed hypersensitivity reaction to develop. The immune response that causes induration typically peaks at 48–72 hours.
C. 1 week:Waiting a full week exceeds the ideal time frame for interpretation. By this point, the reaction may have subsided, leading to an inaccurate or unreadable result. Follow-up must occur within 2–3 days.
D. 1 month:A return after one month is far too late to interpret the results. The test site would have long since returned to baseline, making accurate evaluation impossible and necessitating repeat testing.
Correct Answer is D
Explanation
A. Blood pressure of 138/84 mmHg:This is within the acceptable range for a 68-year-old adult, especially with a history of hypertension. It does not indicate an acute threat or require immediate intervention in the context of pneumonia.
B. WBC count of 15,000/mm³:An elevated WBC count is expected in response to infection, such as pneumonia. While it confirms an inflammatory process, it is not the most urgent issue requiring immediate nursing action.
C. Blood glucose of 198 mg/dL:This mild hyperglycemia is not uncommon in infections and stress responses, particularly in patients with diabetes. It should be monitored, but it is not an immediate danger to the patient.
D. Oxygen saturation 89%:This low oxygen saturation indicates hypoxemia and impaired gas exchange, which is critical in a patient with pneumonia. Immediate oxygen therapy is necessary to prevent tissue hypoxia and respiratory failure.
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