The nurse in a school clinic is caring for a 7-year-old girl who comes in for epistaxis. The nurse will initiate which of the following interventions? (Select the 2 responses that apply)
Apply a heat pack to the bridge of the nose.
Lightly suction blood from nares and mouth.
Have the child tilt her head forward.
Have the child sit upright.
The Correct Answer is C
Choice A reason: Applying a heat pack to the bridge of the nose is not recommended as it may increase blood flow and worsen the bleeding.
Choice B reason: Lightly suctioning blood from nares and mouth is not typically necessary and could be uncomfortable for the child.
Choice C reason: This is one of the correct choices. Tilting the head forward prevents blood from flowing down the throat, which can cause nausea or vomiting.
Choice D reason: This is one of the correct choices. Sitting upright reduces blood pressure in the veins of the nose and may help slow the bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: An elevated white blood count (WBC) is not typically a side effect of chemotherapy; in fact, chemotherapy often leads to a decreased WBC count.
Choice B reason: This is the correct choice. Bone marrow suppression is a common side effect of chemotherapy, leading to a decreased production of blood cells and necessitating precautions to prevent infection.
Choice C reason: T-cell mediated hypersensitivity is not a common side effect of chemotherapy that would dictate the type of precautions needed.
Choice D reason: Stomatitis is a possible side effect of chemotherapy, but it does not primarily determine the type of precautions required as bone marrow suppression does.
Correct Answer is C
Explanation
Choice A reason: Infrequent diaper changes can contribute to diaper rash, but the presence of satellite lesions suggests a yeast infection rather than a simple irritant rash.
Choice B reason: Impetigo, caused by staphylococcal or streptococcal bacteria, typically presents with honey-colored crusts and is not usually associated with satellite lesions.
Choice C reason: The description of bright red scaly plaques and satellite lesions is characteristic of a yeast infection, specifically caused by Candida albicans.
Choice D reason: While urine and feces can irritate the skin and cause diaper rash, the specific clinical findings mentioned point more towards a yeast infection.
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