A nurse is caring for a client who has hypertension and develops epistaxis. Which of the following actions should the nurse take? (Select all that apply)

Tilt the client's head backward

Move the client into high-Fowler's position

Apply pressure to the nares

Instruct the client to blow his nose

Place ice to the bridge of the client's nose

Answer and Explanation

Correct Answer : B,C,E

These actions help to control bleeding, reduce blood pressure, and promote clotting.

a. Tilt the client's head backward. This is not recommended, as it can cause blood to drain into the throat and increase the risk of aspiration, nausea, or vomiting.

d. Instruct the client to blow his nose. This is not advisable, as it can dislodge any clots that have formed and worsen bleeding.

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Correct Answer is C

Explanation

Increased anteroposterior diameter of the chest, also known as barrel chest, is a common finding in clients who have COPD with emphysema. It is caused by chronic air trapping and hyperinﬂation of the lungs, which results in fattening of the diaphragm and widening of the rib cage.

a) Oxygen saturation level 96% is within the normal range of 95% to 100% and does not indicate hypoxemia or impaired gas exchange. Clients who have COPD with emphysema typically have lower oxygen saturation levels, ranging from 88% to 92%.
b) Respiratory alkalosis is a condition in which the blood pH is elevated due to decreased carbon dioxide levels. It is caused by hyperventilation, which can occur in response to hypoxia, anxiety, or pain. Clients who have COPD with emphysema usually have respiratory acidosis, which is a condition in which the blood pH is lowered due to increased carbon dioxide levels. It is caused by hypoventilation, which results from impaired lung function and airway obstruction.
d) Petechiae on chest are small red or purple spots on the skin caused by bleeding from capillaries. They are not a typical finding in clients who have COPD with emphysema, unless they have severe coughing episodes or coagulation disorders. They can indicate infection, inﬂammation, trauma, or vascular disease.

A. Provide the client with a low protein diet. B. Instruct the client to use pursed-lip breathing. C. Restrict the client's ﬂuid intake to less than 2 L/day. D. Have the client use the early-morning hours for exercise and activity.

Correct Answer is B

Explanation

Pursed-lip breathing is a technique that helps clients with COPD to exhale more eﬀectively and prevent air trapping in the lungs. It also reduces dyspnea and improves oxygenation.

a) A low protein diet is not recommended for clients with COPD, as they need adequate protein intake to maintain muscle mass and prevent malnutrition.

c) Fluid restriction is not necessary for clients with COPD, unless they have signs of ﬂuid overload or heart failure. Adequate hydration helps to thin secretions and facilitate expectoration.

d) Early-morning hours are not the best time for exercise and activity for clients with COPD, as they may experience more shortness of breath and fatigue due to diurnal variations in lung function. A better time would be mid-morning or afternoon, after taking bronchodilators and clearing secretions.

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A nurse is caring for a client who has hypertension and develops epistaxis. Which of the following actions should the nurse take? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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